Another great team-up article
If you recall, my last physical therapy authorization article was a team-up with The Note Ninjas. It was so well received I decided another team-up was in order. This time around I wanted someone that could vouch for some of the claims I make. If you have been reading any of my other posts, you might tell that at times I am a bit harsh on you the skilled care providers. It may seem to some that I have a grudge against my fellow colleagues. Well, this is not so. First, I do not haunt a small two level house in Tokyo, and I can’t stand having hair pulled down in front of my face (I bet that is why that ghost was always so ticked off, could no one give the poor girl a comb?). Second, I just know that physical therapy providers in general can be better, and by so doing it can make their work easier and reduce the many reasons care gets stopped for their patients. I just get a passionate.
Interestingly enough, the physical therapist that helped me with this article probably could be a ninja! Or at least you want him on your side when walking down a dark alley. This fellow PT participates in Taekwondo, Gracie Jiu Jitsu, and some Hapkido. He is only a few belt levels away from black belt! He has also been a physical therapist for 20 years. He has been doing clinical review for the past 5. He has worked in both pre-authorization and now focuses on denial coordination. He has seen the good, the bad and the ugly (Crap, I forgot to ask if he is a Clint Eastwood fan… I bet he is).
So today I introduce to you to Bill Daly, PT. Bill currently works at NaviHealth as a denials coordinator. He currently works from home and has a regular 8-5 kind of schedule. Similar to me, he pours through clinical notes all day long. When he is done with work, besides training for that black belt, he spends time with his family and rocks out on the drums!
In communications with Bill it became pretty obvious that we both see a great deal of mistakes that are made by providers. Sadly, it is often these mistakes that cause requests to be placed on hold or potentially denied. If these errors (errors in PT link) were avoided, providers could likely see better authorizations and less frustration. So we wanted to share these errors with you. But you don’t have to just take my word for it.
Bill’s Top 5 PT Authorization Provider Mistakes
- No Clinical information submitted – The rehab provider will submit a pre-service authorization request but does not submit any clinical information to process it. A review cannot be done and so we have to request information again or take other measures depending on the health plan.
- Old Clinical Information submitted – The skilled care provider submits outdated clinical information that cannot be considered. Continuing care needs to be based on the current status of the patient, so if it is too old we cannot use it for a decision
- Misuse of Personal Health Information – Providers or their offices that put PHI on the fax cover sheet. This is a HIPAA violation. Information on the fax cover cannot have personal information. Use of case or authorization numbers should be used instead of names and date of births on the fax cover sheet.
- Lack of response – Especially in the first two mistakes listed, often we have to go back to the therapist to ask for additional information. There is a time period in which they need to get this information to us. The provider’s office is informed of this usually more than once. However, they ignore our requests for additional clinicals and we don’t get anything.
- No contact information – When we go to try to inform them of an issue with a request they never provided a phone number to contact them.
Bonus: Clearly inappropriate need of skilled care – They request a skilled nursing authorization even though the patient may be walking 500 feet and is independent with transfers and ADLs (or similar).
NaviHealth reviews primarily for post-acute care. So this is a bit different where I see a variety of settings from post-acute, snf, alf, outpatient and home health. I can agree with each of Bills Top 5 no matter the setting. These are just simple, common mistakes made throughout PT authorizations. What I love about Bill’s list is these are errors that can so easily be changed today to better improve your requests for additional skilled care!
Thanks so much for the insight Bill. Maybe we should nick-name him the “Chuck Norris” of Physical Therapy? Certainly look this guy up at the links provided above.
While we are here, I wanted to pass along a few mistakes I see all the time as well. We may work in similar settings, but as mentioned, my perspective is a bit different. I think that if you combined our lists and used them in how your clinic manages authorizations you would start to see significant improvements. Here a few of my additional top mistakes:
- 100% agree with Bill’s #1 – No clinical information sent. I even wrote about this in my two part series on why care is denied with The Note Ninjas. I can’t say it enough! Just don’t send a blank request, O.K.?
- Low quality information – I see this all too frequently both in outpatient and home health care. Notes that are just pathetic. I like to call these “The Four Sentence SOAP Note”. These kinds of notes make we want to pull my hair forward and go haunt some PT clinics. This is pure laziness. You spend a whole 45-60min with a patient and all you can get is 4 lines to put on paper? You must insure that your documentation is defensible. For now (until I write an article about this) I found a great resource from the American Physical Therapy Association about integrity in your documentation. Here are their bullet points:
- It serves as a record of patient or client care, including a report of the individual’s status, physical therapist management, and outcome of physical therapist intervention.
- It is a tool for the planning and provision of services and is a communication vehicle among providers.
- It tells others about the physical therapist’s abilities, unique body of knowledge, and services provided.
- It demonstrates compliance with federal, state, payer, and local regulations.
- It provides an historical account of patient and client encounters that can be used as evidence in potential legal situations.
- It may be used to demonstrate appropriate service utilization and payment for many payers.
- Not asking questions of the health plan or third party – It is quite often that I speak with providers that just do not understand the authorization process. They don’t know what to send or what forms to use. They haven’t the foggiest idea what was previously authorized. I know this process is not easy, but many just choose to stay in the dark. They don’t ask questions. They immediately assume visits are denied just because the insurance company just doesn’t want to give visits. However, I would say that many times, a request for visits is not approved just because the request was not complete. When care is not authorized start asking appropriate questions:
- Was there something not included that should have been?
- Are their specific forms that should be used?
- Is there better information to give in the clinical notes? (here is one example from BCBS of Kansas)
- Not reading the authorization/denial letters – Each company is going to be a bit different in how they communicate back to you about a request. That being said, they should all give rationale to their decision. They have to communicate this to you in some way. Are you reading these decisions? Pay attention to these.
Great for Business, Great for Patients
There you have it, some real simple, yet solid tips on very common mistakes you, or fellow co-workers, could be making every day with your rehab authorization requests. As you can see, many of these errors require little to no effort to fix. Avoiding these mistakes in your physical therapy, occupational therapy and chiropractic offices will make your work easier. As you work just a bit more closely with the health plans and review companies you will better understand the processes.
One more ending thought (sorry, can’t stay up late tonight, I have The Great British Bake Off to binge watch. That’s right, don’t judge. . .). Many clinics make some if not all of these mistakes. Unfortunately, these mistakes can affect the impression the patient has of your clinic. These mistakes cause frustration for staff and for you. This frustration is often passed on to the patient. Provider offices complain to the patient about their insurance and their benefits. This can give the patients a negative impression of the clinic and the care they get.
But . . . what if your clinic is one of the only ones in the area that gets the process? Your clinic doesn’t have to place patients on hold. Your front office is not frustrated. The patients are not made to feel their insurance is inferior. Are patients going to notice this? You bet they will. Not only can these tips improve how well your clinic runs, they can actually help improve the impression the patient gets. They can help the patient keep their trust in you and your staff. That is worth the little time and effort it takes to do things right.
A huge thanks again to Bill! As always, thanks for reading. I certainly welcome your comments and questions. If you need additional help, please reach out. If you happen to see any creepy ghosts with hair in front of their face, maybe offer them a comb. Now, to learn how to prevent a soggy bottom!