When the utilization manager makes the ‘faux pas’

Before I write any further articles I really want to make something perfectly and publicly clear.  


More specifically, even in physical therapy clinical review I have made mistakes.  Mistakes are made everyday in rehab authorization review. As much as we in utilization management try, mistakes are going to be made.  Most often these are small mistakes that may have little to no impact on your patient care. Unfortunately, there are times in the clinical review process when big mistakes are made. So I am going to highlight some of the top mistakes made by clinical review companies and what you can to reduce, avoid and correct them.

Deep down in our hearts we all know that we make mistakes.  Some may have to dig a bit deeper than others to find this understanding.  It can be hard to accept or admit. We want to think that some institutions are infallible.  Hospitals, childhood heroes, religious groups, CEOs, banks . . . Government, news stations, the local meteorologist (hey, one can dream!). 

Even within physical/occupational therapy/chiropratic mistakes are made thousands of times a day throughout the world.  I am sure we have all witnessed patients getting burned by hot packs, frostbite from ice packs, mobilization gone awry, slips, trips and falls by patients.  Some of these are due to negligence, some just bad luck. What about smaller mistakes; set-up the ionto but then never turned it on, forgot about the patient in the room and they just fall asleep for the next 30 minutes, started the patient weight bearing and then realized that was not supposed to be done until next week (interestingly each patient “feels great” after each of these mistakes).  Would you permit a slight biblical reference here?

“…he that is without [having ever performed an entire ultrasound without the power turned on at least once] among you, let him first cast a stone” (John 8:8) [text in brackets changed for comedic effect]

Just in case you missed this classic episode.

O.K. so we all make mistakes right?

Oh, but the frustration is just killing you!!

Despite our knowledge that everyone makes mistakes, when these mistakes affect our ability to be productive and earn money, we forget that along the way sometimes.  Then enters frustration. Especially when mistakes are made again and again. When the party making the mistake does not seem to understand or learn from their mistake.  I mean, is there really a good reason why men can’t remember to put down the toilet seat!?! (Pee-s – yes men can learn to do this, most learn to do this, I do this. It is just the minority giving us a bad name. I blame the Illuminati)

I certainly understand that a mistake that holds up getting a skilled care authorization can be extremely frustrating. As much as I hate to admit it, this does happen. I agree that authorization mistakes are unfortunate. They impact patient care.  They impact your therapy business and potentially your reputation. So what can be done, shall we proceed?

7 Top Utilization Management Mistakes

1. Your case gets entered into the system incorrectly – this could be any number of small mistakes that happen at the initiation of the review company getting your request.  Most companies will accept a new PT/OT/Chiropractic/acupuncture request through one of three ways: phone, fax, online portal. Especially true for phone and fax requests, the next step will be an agent inputting the information into the system.  So right from the get go, human error could potentially show its ugly face. Even the smallest typo could lead to other mistakes (like the authorization not getting back to you on time). Maybe a name was spelled wrong, or a number was typed incorrectly.  So then if the patient information or your facility information is correct the final authorization may not work when you go to bill for services. You may never hear back. The worst part is that it may take a few days or several weeks before the mistake is caught. Suggested solutions:

    • If at all possible use an online portal to submit and check requests.  This eliminates one additional step a human takes and where error can occur.  You can also check your submission to make sure you got everything correct. Not all plans allow this yet, but for those that do. Use it
    • If making submissions by fax (hear that annoying dial-up internet tone? Ya, that’s 1990 calling) be sure to write extremely clearly, or better yet type your request.  Even though you think your handwriting looks great the difference between a 2 and Z or 5 and S is very small. Faxes get distorted easily and increase the chance of a mistake.  Also, don’t ever fax a copied page, they look 10x worse on the receiving end.
    • If making submissions by phone ask that the agent on the other end repeat back the information you give.  Speak clearly and not too fast. Take the time to get it right the first time to avoid a second call to correct the case.

B. Your case gets built for the wrong type of service – Much like the above mistake, this one is also just a basic data entry issue.  Whomever started the case entered the type of skilled care incorrectly. Most often this is getting PT and OT mixed up. So you wanted a case started for Occupational Therapy, but it ended up getting created for Physical Therapy (or the other way around).  As with the above, make sure your request is clear and legible. A few other suggestions:

    • Clearly mark which type of care you are requesting each and every time.  Whether on their form or your fax cover, make it clear what you are needing.
    • Send separate requests for each type of care being requested.  This is where I see the mistake happen the most. The same patient is in need of PT, OT and Speech.  So the office staff sends all three requests together with one fax sheet and everything just jammed together.  It may make sense to you, but the agent on the receiving end that creates the case most likely is not clinical and may not understand which information goes with which request.  So, greater risk of mistake making. Take the extra couple of minutes to send each request individually with individual fax sheets or as individual uploads.

Tres. Your faxed information is incomplete or missing – In this digital age, faxes are just hogwash.  I see several cases everyday where parts of faxes or entire faxes were never received. It is exponentially worse than whatever monster eats single socks from your dryer. Not only can some or all of your fax be missing, they can also get distorted during the scan process.  They can be received much lighter in color, much darker in color, distorted, wavy, only ½ the page was scanned, or any other scanning issues. Just because you get your “OK” report back does not guarantee it was received ok. Hopefully, these mistakes are caught on the receiving end and a call out is made to you to resend it, but that could take several days for the company to see the mistake and get a hold of you. Here are some things to help:

    • Just like dogs foaming at the mouth, men with mullets and subway bathrooms (station or the sandwich joint); avoid faxes as much as possible. You may need to use it at times, but do so with caution.  This is just old technology. It’s ok to let some parts of the 90s die.
    • If you do need to fax, try to set it up through your computer vs an actual fax/copy machine.  These tend to be more reliable and at least more readable on the other end.
    • Use a fax cover sheet that lists the number of pages you sent and that clearly has your request marked.
    • Do not send long faxes!  Unless the company specifically requests all the medical history for the patient, don’t send it.  Get educated on what the different review companies require and try to send the minimum. Long faxes use more memory and create friction/heat in the machine.  Memory can go bad and friction/heat can case the machine to do funny things. If you must send long faxes break them up each with a new fax cover sheet clearly marking “part 1” “part 2” etc.  

Δ. Your case gets completed too late – This mistake can be very frustrating for you the provider office.  I totally understand that. All cases for pre- or post- authorization have specific turnaround times. These time limits are set by the health plans, so there is great variability.  I have seen some as soon as 24 hours and others as much as 12 days. Appeals can be even longer. Either way, not getting an answer on time can affect patient care. Some of the primary reasons for this error are computer system issues, manpower issues or act of God issues that affect the utilization management company.  

Where I work, our servers have issues all the time that create backlogs. We also have time periods of high turnover with agents that create cases. These are entry level jobs often filled by students and young people whose lives change, so people are always coming and going. We also have several offices in areas that are prone to hurricanes.  This being said, it is the UM company’s responsibility to manage these issues. When cases are not complete in time, the UM companies get reduced money from the health plan, or even get fined. So they try very hard to get things done on time. What can you do about it though?

    • Send in your requests early vs late.  Leave a day or two cushion. Again, some health plans only allow you to have a new start date a few days in advance.  Knowing these time limits is important. If you know your patient is almost out of visits try to send the request before they are completely out of visits.  If you want your authorization to start 3/14, don’t be sending it in on 3/14 or 3/15. Try to anticipate whenever possible. I know this is not always possible for evaluations and such though.  Sometimes it is just bad luck
    • Call or check your online portal.  They case may have fallen prey to one of the other mistakes above without your knowledge.  If the turnaround time has come and you have not received anything, get in touch.

🖐. You never got a response back after submitting a case – A submit a request for more rehabilitation but never hear back about it.  I agree that this would also be very frustrating. It can make it hard to coordinate patient care if visits need to be missed or you fear giving treatment without authorization in place.  In my experience, the main reasons for this are: 1. the determination fax the UM company is required to send out has an error in transmission or, 2. the contact information in the system for your office is not correct so it gets sent to the wrong place.  

Yep, the whole fax thing over again. Believe me, my eyes are rolling just as much as yours. It is my understanding that UM companies are required to send a physical notice (letter of some kind) for each determination. So instead of using the good ole US postal service they use fax to send the letters so providers don’t have to wait days or weeks – or forever – to get the mail delivered.  A couple of suggestions:

    • Again, check your online portal if you can to track requests and their statuses, if the case is not there, call the company.
    • Track turnaround times and if you have received anything, call the company.

VI. Your case was not reviewed appropriatelyI know you are all thinking that the decisions made by therapists that do the clinical review are 100% correct but . . . we might make a review mistake every once and again 😉.  By this I mean a true mistake, like we miss seeing information, hit the wrong button, type the wrong number. I do not mean you getting a decision you just don’t agree with. We are as fallible as you.

We have many systems and processes in place to avoid mistakes as much as possible.  Mistakes cost the review companies money. Mistakes during the actual review process are minimal, but will happen. Generally you will not know a mistake happened unless the authorization comes back really strange. You asked for 12 visits and got an approval for 122 visits! Of course, you do the honest thing and call to correct it right?  In general however, you would just get back a determination that appears normal but may not seem quite right. Maybe it was the first one ever sent in for a patient and it came back denied. Maybe the rationale listed states the visits are for a completely different body part. Those kinds of things. In all of the instances, here a few ideas:

    • Call the company ASAP to alert them it does not seem right.
    • If the agent you talk to does not seem to understand, request a peer call.  It might take you talking directly with a reviewing therapist to have them inspect to see if it really is correct
    • Make sure the information you submit is clear.  I DO NOT recommend any provider send in handwritten notes this day and age.  Just because you can read your handwriting does not mean I can. (Most often I would say we struggle to clearly ready even women’s handwriting, sorry ladies, this proverbial toilet seat is left up by all genders!)

neveS. Your case was denied, but the patient VERY clearly needs therapy – As in the previous mistake, this could happen by the reviewing therapist hitting the wrong button.  It could also happen before it comes to us. It could be an eligibility mistake where the patient was not showing up in the system so a case could not be built and is denied before it is finalized.  It could be the fax never showed up and the health plan has a short turnaround time, so it was automatically denied. Regardless, here are a few last tips to think about:

    • Some online portals will allow you access to the notes placed in the request that was denied.  I don’t mean the clinical notes, but the notes entered by the UM agents and reviewers. Check those to see the denial reason.
    • Call and ask an agent to help you understand what happened.
    • Get into the habit of having the patient verify their own benefits as well prior to starting care.  I don’t think it is asking too much to ask them to call their health plan and verify their benefit and see if there are prior-auth requirements.  You could even create a little info page on what they need to ask and to bring it to their first appointment. That way, even though you have called, the patient now understands their plan better and you can compare what they were told with what you were told. This will help in avoiding issues related to eligibility, etc.    

Like I said above, mistakes cost the utilization review companies and health insurance companies money.  They try very hard not to make them, but it is inevitable. Generally, they should be more than happy to help correct mistakes they have made.  If you are contacting them, just approach it as a genuine concern that a mistake might have been made. Don’t be a jerk, don’t make threats. How often does that usually help a situation?

Use your wits, as no matter who makes the mistake there could be something to learn . I have also experienced where the provider calls in “with guns blazing” and verbally tares me up and down, insults, vulgarity, questioning my license, saying we made a huge mistake, blah, blah; to only find out their front office never sent the information, or they sent the wrong information.

Hey, can I get an order of Humble pie for the pencil necked provider over yonder?  What’s that? . . . Yah serve it cold. Thanks

Thanks so much for sticking with me on this one.  It was a bit longer than anticipated, but I know the tips can help your practice run just a bit smoother.  Even if you can help avoid 3-4 mistakes a month, that is already a couple of hours you or your office didn’t have to spend on the phone. Mistakes will happen, but we can get through and learn from them.  Closing us out tonight with some appropriate lyrics from a favorite song:

I’ve paid my dues
Time after time
I’ve done my sentence
But committed no crime
And bad mistakes
I’ve made a few
I’ve had my share of sand kicked in my face
But I’ve come through

We Are The Champions – by Freddie Mercury. Queen ©1977

A great follow up read – Medical Necessity In Rehab

Please follow and like us:

Leave a Reply

%d bloggers like this: