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Physicians Practice® spoke with Kristina Hutson, a product line developer at Availity, about surprise billing events in independent healthcare practices and what owners and administrators can do to reduce the likelihood of their occurrence.

How to reduce surprise billing in your practice

Physicians Practice® spoke with Terry Blessing III, Senior Vice President of Client Development at VisiQuate, about how practices can work to reduce the likelihood of encountering denied claims.

Avoiding Claims Denials in Your Practice

: Today we are presenting our conversation with Steve Avery, president and chief client officer at 

—a company specializing in revenue cycle management—where we discuss the practice of 'surprise' or 'balance billing' and how practices can navigate this increasingly complex landscape.

Our conversation specifically addressed anesthesiology practices; however, the general takeaways should also be applicable to primary care solo and small group practices.

We began by discussing whether or not there are ways for practices to know ahead of time if a patient coming to their office is covered under a partnering insurance plan.

 Well, I guess the first thing is, I want to add a little perspective around that question. Just in the country, there are thousands of health insurance plans. And not every health insurance plan has prominence in every community. So, the average anesthesiology group working at community hospital may have about 30 to 40 health insurance plan-specific contracts. So, it's not out of the question that a patient could come to the hospital with an insurance policy, that's not one of the 30 to 40 plans that are under contract with the anesthesiology group.

For the providers that we work with, they're all very diligently working to have contracts in place with the insurance companies that are likely to have patients in the area. The answer to the question is that anesthesiologists may not always know if a patient is coming to the hospital that has an insurance policy that's under their contract. The situation can be further complicated by an unfortunate occurrence where the patient is coming to the emergency room to be treated and then straight to the operating room, very little may be known about the patient at that time, especially the type of health insurance that they may have; unfortunate, but it happens like that sometimes. So, you know, we don't always know ahead of time.

: If you are able to identify that a patient is not covered under a partnering insurance plan, you may be able to communicate this coverage discrepancy prior to performing services.

: Well, if you do know ahead of time, and there are certain times where we may get a tip off from the hospital, that patient's not covered under one of the insurance policies, the optimal situation is to reach out to the patient well ahead of the data surgery, and let them know that the provider doesn't have contract with their particular insurance company.

This gives the patient the opportunity to work with their surgeon to select another facility where the anesthesiologist does have a contract with their specific health insurance plan. So where you know ahead of time you can make, you could make alterations or change the location of the surgery just to make sure that the patient has the best outcome possible.

: Avery did provide three things that practices can do to ensure that a patient is prepared to meet the cost of your services.

: Yeah, I think there are really three things that they can do.

Its first, you know, work with the patient. Second work with the insurance company. Third, involve the patient where necessary to work with their own health insurance company to resolve any situation.

The patient needs to know what to expect. And really, communication is very key. They need to know what happens after the surgery and what financial impact this may have on them as a result of the procedure. So, what you have to do is tell them that you're going to work with them, try to ease their anxiety about the unknown. And many times insurance companies will work with the anesthesiologist to negotiate a more favorable reimbursement rate, that will reduce the financial impact on the patient. In the case of an emergency where the patient could not select the hospital, much less the anesthesiologist, the insurance company may offer rates and terms for the for the provider that really kind of mirror the reimbursement that a provider would normally receive if they were under contract for that particular insurance company.

: Beyond discussing payments with patients, balance billing has been cited as a negotiating factor for practices.

: Balance billing legislation really does more to complicate things for the anesthesiologist than it really resolves. In many states where legislation is in place, the insurance company sometimes has a negotiation advantage over the anesthesiologist. If the anesthesiologist does not have a contract, they're reimbursed usually at a very low reimbursement rate typical for that particular geography or not typical with average reimbursement rates for that geography. And then to complicated things they can't build a patient for any unreimbursed portions procedure.

If they do have a contract, then you know, complications occur when they try to go back and renegotiate any terms or any increase in reimbursement. It becomes less than likely, since the alternative is to have is to not have a contract, and really become a financial disadvantage in the marketplace. So, the question should be does the legislation benefit the patient? Or the insurance company? Maybe both. In many cases, it does not benefit the physician, they're now at a disadvantage in those in certain circumstances.

: So surprise billing generally complicate aspects of the treatment process for both the patient and physician or practice. Should this then be something that practices are actively attempting to suppress, or will it remain something that just occurs at the end of the treatment cycle?

: You know, I think they should, and practices should work to have contracts in place with all the insurance companies that are under contract with the hospital; mirror what they do. And many times, for groups, this is a contractual requirement. In order for the anesthesiologist to have a contract provides services at the hospital, they have to agree to have contracts with all of the insurance companies that are contracted by the hospital. I think it's also a matter of ethics, meaning providers should want the patient to have a positive experience when they're being taken care of. In short, they should want to help the patient medically and financially by helping them to navigate through what could be a very difficult situation.

: This may all come down to a question of reasonable costs – how then should practices be determining this reasonable cost?

: Well, anesthesiologists or any other practice for that matter are financial entities, and they need to provide market wages for the doctors and the supporting personnel that work for the practice.

The market really determines the wages in the in the area. They also determine the reimbursement for that provider in that particular mark. So sometimes, you know, when there's a political solution that tries to solve a specific problem, the market sometimes gets removed from the equation, just like in the surprise billing legislation. In this case, the provider becomes the one to suffer financially. If you let the market work, the anesthesiologist and the insurance company will in large part reach an agreement on what is reasonable reimbursement for the services they provide.

Physician's Practice® spoke with Steve Avery, president and chief client officer at Abeo, about the practice of surprise billing—a practice that can present complications for, patients, providers, and the practice as a whole.

Surprise Billing in Your Practice

 Last year, The American Medical Association released results of their prior authorization survey, which found that physicians were completing an average of 33 prior authorizations per week, waiting an average of two whole business days for approval. The entire approval process had become so burdensome that some respondents reported increasing their staff specifically to deal with the increased burdens of prior authorizations.

We spoke with Paul Joiner, chief operating officer of Availity, to flesh out some of the results from the survey and find out how primary care practices can improve their prior authorization processes.

In case you are new to the concept of prior authorizations, here is a brief explanation from Paul.

 So prior authorization is a process in which providers have to go through on behalf of their patients to get approval from the health plan to provide a service and get paid for it. This process is often reserved for procedures and diagnostics. It's probably the biggest burden in the diagnostic process, just because you're anxious to get to a diagnosis. You'll also hear it referred to as pre certification. And then sometimes there's other confusing topics, like notice of admission sometimes gets called a ‘preauth’, with people technically, because of a common transaction name, but by and large, in general, pre authorization and pre certification is an approval prior to service from the health insurance plan to perform a procedure and get paid for it.

 Paul mentions radiology, but he also said other treatments that typically require prior authorizations are those that require some medical guidelines before administering or performing, including many preventative diagnostic type tests.

Furthermore, they are intertwined with electronic health records, which may present additional hurdles.

 Well, they are because the source of information for supporting the need for the diagnostic test or for that procedure lives within the medical records. So proper documentation and understanding what is needed to attain the authorization is very, very important. It's important from a training perspective. And it's important that this team working on the authorization process is giving that feedback to the physicians, the physician extenders, so the medical assistants, the nurses and the physician assistants, if you will.

 Regarding the report mentioned earlier, Paul says that the average two-day wait time for prior authorization decisions is due to the fact that every health plan handles various authorization types differently.

 Sure, well, every health plan handles various authorization types differently. It takes two days, because one, the sheer volume, and then two, it requires a lot of these requires some type of clinical review and some type of clinical back and forth. And those are limited, expensive, highly skilled, specific resources. And then the back and forth part is, is that many times, there's a level of clinical information that needs to be supplied. And sometimes there's a back and forth conversation that needs to occur before the final disposition of the pre-authorization or the approval or the denial of the authorization can be can be given. And so many times, providers get very frustrated because they're a little confused about the status of the prior authorization, and how plans sometimes struggle to convey that status back to the providers. Obviously the patient's anxious to move on, so it creates a lot of anxiety, but it's a function of resources, the function of the complexity of the process, and in the back and forth conversation sometimes has to occur.

 Also mentioned in the report from the American Medical Association is a reported increase in a sense of burden among respondents. When asked whether or not this burden was perceptual—that it was an incorrect assessment from the physicians—or whether their sense of burden was actually due to requirement changes and increases in complexity, Paul says that it is certainly the latter.

 Requirements are truly been being increased. The level of which, the types of procedures, the variety of procedures, and diagnostic tests that requiring prior authorization is increasing. And then the nature in which these procedures and services are being scrutinized has been ratcheted up.

To the health plans’ credit though, many health plans are trying their best to innovate and improve the process and exchange of clinical information and make it clear to providers on when a prior authorization is required, and information that they need in order to give the prior approval.

You know any recommendation I would give to any provider or any physician especially if they're new to practice or long established, take a second and spend a couple extra moments with your staff and to make sure the process is worked out. And you as a physician know how you can help and how you can provide the proper documentation to facilitate the process or make sure the process is moving. smoothly.

And then the other thing is, is a lot of this misconception going back this 86% of burden increase. There's a lot of misunderstanding between the providers and health plans. And so, if something doesn't make sense, I encourage the providers to reach out to the health plans and have a conversation about it. Because a lot of times, it's a process or a structural issue in terms of how the information is being sent to the health plan, or the way that information is being interpreted creates a lot of confusion, a lot of problem between the providers and health plans, which increases the burden.

I've seen examples where providers have sat down with health plans and worked out and improve the process. And there's always going to be a little friction to the process. But it definitely can be reduced if you just take the time to kind of learn the process, both internally and also engage the health plans.

 Requirements from health plans are not the only way in which requirements, and subsequent physician burden, are increasing. Paul says that there are some legal and regulatory changes that can affect the prior authorization process as well.

 Well, there are in there are different mandates out there trying to improve the process. In fact, I just participated in and testified to Washington organization in relation to the improvement of the process and different operating rules. Core is putting for roles, the AMA is obviously involved. There are other technological advances that will could probably change the authorization process there since the Da Vinci project, which is a clinical information interoperability initiative that's underway. So, there's a lot of pressure from the federal and state governments to improve interoperability to improve the process. Really, where a lot of the technical legal stuff happens is that if you perform a procedure, and the payer denies it, because they don't think proper authorization was in place, that does trigger a formal legal process that does vary from state to state.

 Though some practices said in the American Medical Association report that they were increasing staffing levels to deal with the prior authorization process, Paul says that improvements do not stop at the hiring process.

 Well, yes, staffing. I'm familiar with one practice. You know, a dozen years ago, they had two people working prior authorizations, and now they have eight, it's a practice I'm familiar with. And so, number one thing around when you're increasing staffing is training. So, make sure that you're working hard to evolve your training with the times and staying current corporate policies, and that you're just not perpetuating common myths and workflows that you're constantly improving as you're training your employees.

Number two, invest. Invest in these in these resources that you have in the authorization problem and make sure that are of a high caliber, because there is a valuable payback in terms of them being a sophisticated resource and capable to navigate the system and capital is also capable to, you know, interpret how this process is changing and how the payers are changing.

Next on the process side, you can subdivide the authorization work by payer type, by procedure type, so you can subdivide the work. And that typically helps because then your resources can get more and more specialized and more and more focused in terms of information they're collecting, and who they're communicating with. Because many health plans outsource certain segments of the authorization process to vendors. Radiology benefit managers is a common one, you'll hear where there's an actual health I know speaking with, they're actually speaking a company, who providers provides the UN services or the authorization process to the provider to the health plan. And then providers have to engage the UN vendor. So, from a process perspective, it's about how can you subdivide the work and make sure the work is prioritized and bucket in terms of the most complex the least and make sure the right people working on the right task.

Then from the technology perspective, there's all sorts of opportunity to think through the person trying to attain the authorization and the approval making sure they have all the proper clinical documentation. And then try to understand and engage with that your largest health plans on what tools they have available to you to submit for an authorization or check the status of it. Besides picking up the phone and calling. One thing I want to share that is a common issue that a lot of providers think that they'll go through a solution like you know like Availity has or other vendors have in relation to electronic submission or authorization. I've heard numerous for physician practices say well I also call even if I get an electronic because I want the name and phone number and I want documentation that got called to double check or for an extra level of verification that the authorization is in place because I do not want to denial after treatment. So, despite so what that means is despite electronic channels and technology channels, and integration channels, they're still calling the health plans and trying to write down the name of a call center and the name or name of the time and a reference number for that phone call. So that they have that additional evidence that they did obtain authorization in the event that their claim was denied for that service because prior auth wasn't on file.

Physician's Practice spoke with Paul Joiner, chief operating officer of Availity, to discuss the implications of an American Medical Association survey and find out how you can improve your prior authorization processes.

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How to reduce surprise billing in your practice