Referral and Authorization Denials: Thinking Outside the Box Webinar

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Click to edit Master title styleReferrals & Authorization Denials:
Thinking Outside the Box
Megan Smith
Executive Director of Quality & Training
Healthcare Resource Group

Objectives
• Explain the difference between referrals and authorizations and
which insurance plans require referrals
• Describe common authorization workflows
• Submit a strong first level appeal with applicable back-up

Medical Benefit Hierarchy

Definition of Referral
A referral is the process of
directing a patient to a medical
specialist by a primary care
physician
referral

Types of Commercial Plans
Health Maintenance
Organization (HMO)
Choose in-network PCP
Referral required
No out of network
benefits
Preferred Provider
Organization (PPO)
PCP not required
No Referral required
Out of network benefits
available; higher out of
pocket
Exclusive Provider
Organization (EPO)
PCP not required
No Referral required
No out of network
benefits
Point of Service (POS)
Choose in-network PCP
Referral required
Out of network benefits
available; higher out of
pocket

Definition of Authorization
authorizationAn authorization or precertification, is the
process of reviewing certain medical,
surgical or behavioral health services to
ensure medial necessity and
appropriateness of care prior to services
being rendered
Prior Authorization
Authorization of services prior to the service date
Examples include: Surgical procedures, Advanced imaging
(CT/MRI), Infusions
Retro Authorization
Process of requesting authorization after service has
been performed
Inpatient Authorization
Authorization of inpatient stay based on the payer’s
determination of medical necessity

Authorization Workflows
Provider
orders
service
Prior auth request
submitted to
insurance
Medical records
submitted to
insurance
Insurance responds
with approval
Patient
receives
service
Prior
Auth
Retro
Auth
IP Auth
Provider
orders
service
Retro auth request
submitted to
insurance
Medical records
submitted to
insurance
Insurance responds
with approval or
denial
Claim submitted to
insurance
Claim submitted to
insurance
Claim denied for no
authorization
Retro auth request
submitted to
insurance
Medical records
submitted to
insurance
Patient receives
service
Patient
Admitted as
IP
Inpatient
notification made
to insurance
Clinical records submitted to insurance in regular intervals
Initial clinical
records sent to
insurance by UR or
UM Dept.
Insurance Case
Manager reviews
for medical
necessity
Insurance notifies
hospital of
authorized days or
denial
Patient discharged
or transferred
Claim submitted to
insurance

Appeal Etiquette
5 Rules of Denial Appeal Writing
1. Short and to the point; no more than 1 – 2 pages. No more than 3-4
sentences per paragraph
2. Focus on the positive; never state fault
3. Keep it factual with neutral tone
4. Do your homework; include regulations, payment policies, contract
language, etc. that’s favorable to your position
5. Play to your audience; it doesn’t have to look like legalese. Most 1st level
appeals are reviewed by non-medical, customer service level staff

Appeal Letter Structure
Inpatient Stay Appeal
Paragraphs 2 & 3:
Provide brief history of events. Be
sure to include dates and times
Paragraph 1:
State intent of
letter

Appeal Letter Structure continued
Inpatient Stay Appeal
Paragraph 4:
Rebuttal
Paragraph 5:
Close out by stating request
BE SPECIFIC

Compiling Medical Records
5 Rules for Sending Documents with Appeal
1. Don’t just send entire chart; tell the ‘story’ for claim charges
2. Include physician orders and referrals (when applicable)
3. Lab or imaging; always send both order and results
4. System screen capture OK – be sure to label
5. Presentation of records is critical

Research Tips
hrgpros.com
Most commercial, state and federal
plans have guidance online
Search using keywords payment
policies, clinical policies, authorization
requirements or list

Referral and Authorization Denials: Thinking Outside the Box Webinar

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