Transitioning from a hospital to a skilled nursing facility (SNF), or from a SNF to home health care can be a time of uncertainty in a patient's life. Having an organized, effective process in place for authorizing home health services in advance can take one worry off of the patient's plate while helping to protect the service provider's revenue. Despite its complexity, mastering the authorization process is essential to the success of every home health agency.
In that regard, understanding each step of the authorization process is paramount in developing practices that support timely authorization of services.
The process starts before the patient is even admitted to skilled nursing or home health. During this time, it's important to answer the following questions accurately:
What services does the client need, and how often does he or she need them? For example, they may need physical therapy twice per week, occupational therapy once per week, a home health aide visit twice per week and intermittent skilled nursing care twice per week.
Why does the client need these services– or what is the qualifying diagnosis? In the case above, the client may need these services because they're rehabilitating after a stroke. Knowing the diagnosis is essential for authorizing the services with the payer.
Who is the payer? Because each payer has unique requirements for authorization of home health services, knowing which payer will be paying for the services is imperative to helping ensure thorough and accurate authorization.
What is the client's name, date of birth and policy number? Having this accurate information will support timely completion of verification and authorization.
Inaccuracies in the information collected during the pre-admission process can lead to delays in authorization or admission—or to services rendered without payment.
During intake, verification and authorization are completed.
Verification refers to the process of reaching out to the payer to ensure the client's policy is current and confirm coverages, copayments and co-insurance. Without verification, services may be provided under pretense that the client is covered by one payer, when in fact, they've had a change in coverage or there is an error in their record. This can lead to providing services without appropriate authorization, ultimately resulting in non-payment for those services.
Authorization refers to the process of getting the services approved by the insurance company prior to delivery of those services. Some insurance companies require one-time authorization; some require authorization prior to every appointment; and some require none at all. Knowing which payers require authorization – and for which services – is critical to ensuring payment for services rendered.
As a best practice, the home health agency should maintain a database as a quick reference, outlining which payers require authorization for common home health services and which payers don't. This streamlines the process and eliminates a step when you've worked with the payer before.
It's a common occurrence in home health that the need for services would extend beyond the original authorization. As an example, perhaps you requested four weeks of physical therapy twice per week, but the patient has only regained half of the range of motion you would expect and they now need two additional weeks. This typically requires another prior authorization.
Likewise, some insurance companies will only authorize one appointment or one specified period of time at once, which means home health agencies must submit prior authorizations multiple times according to the patient's needs and the payer's requirements. This is often missed when agencies don't utilize EHR notifications to alert them to the need for additional authorization. Consequently, the services are provided and no payment is issued.
Why can getting prior authorization be so challenging for home health agencies? Three reasons in particular:
It involves multiple teams from pre-admission to intake and even IT personnel. Without seamless collaboration, it's common for prior authorization to fall through the cracks.
Teams that focus on authorization are often focused on the earliest stages in the patient's care—pre-admission and intake. This can leave gaps later when insurance companies require ongoing authorization.
The authorization process is incredibly difficult to streamline without optimized EHR solutions or requisite experience. Prior authorization is an area of expertise by itself with a myriad of moving parts, intricacies and shifting deadlines that can be difficult to track without proper EHR configuration and/or prior authorization experience and expertise.
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