Ron takes his 10 year old daughter, Emily, to the doctor because she has been getting terrible, throbbing headaches recently. Often her vision is blurred and she feels nauseated. The doctor diagnoses her with migraines, but because the problem is new, the doctor orders an MRI to rule out any other possible causes. Emily’s father is relieved because it does not sound too serious, and calls to schedule her MRI. The closest MRI center is only open during typical business hours, so Ron will have to take time off of work and take Emily out of school early, but it is worth it for the peace of mind.
Emily, being the curious 10 year old that she is, begins researching about MRIs. Excited to learn what they are and what happens with them, Emily gets a bit concerned and suspicious. It takes extensive bargaining and reassurance with her father to coax Emily out of the car at the MRI clinic, however they arrive on time for their appointment. Shortly after checking in, Ron is informed they cannot perform the MRI today because they do not have authorization from his insurance company.
“What?!?” Ron said, “That’s impossible, the doctor sent over the paperwork this morning, and nobody said anything else! Why can’t we get the healthcare we are paying for?”
Emily’s doctor sends patient information via fax, even though it is the 21st century, and that morning was no different. The office sent the paperwork over, but never replied when the MRI clinic discovered some missing information.
Ron is livid! From his point of view, half his day will be wasted, and his daughter’s symptoms will not get the care and attention they need. Ron calls Emily’s doctor. The office staff informs Ron the employee responsible for completing authorizations is out with the flu. Other people in the office know what to do and could step in to help out, but nobody has done so. Finally, Ron speaks with the office administrator, who asks one of the nurses to call in for the authorization. The nurse spends 10 minutes on hold, then spends another 10 minutes discussing the case to prove it is medically necessary, and ultimately gets authorization.
Though they are behind schedule, the imaging center is able to fit in the MRI. The authorization took longer than expected because the ball got dropped, but who was at fault? Should the MRI clinic have verified pre-authorizations? Should Ron have known better. After all, it is his plan. And should Emily’s doctor been more proactive in getting the pre-auth, or information the patient of their responsibility? Luckily the stat call from the nurse saved the day. Otherwise Ron would have had no choice but to reschedule, and everyone loses out.
Many patients go to great lengths or struggle to coordinate a time to fit in an MRI. When a patient arrives on time for their appointment and can not receive their MRI, it hurts everyone. Scenarios like this can occur because of multiple reasons, including a complete lack of standardization for pre-authorizations. There’s no clear rule of which office should obtain the authorization, so they are easily overlooked until the day of the appointment, or when needed most.
Does your office have an efficient system in place to manage pre-authorizations?
Next Health Choice takes ownership of the authorization as soon as the order is created. If there is an issue that may result in a delay, everyone involved is notified.
In this case, a lot of time was wasted and used inefficiently. The ordering provider did not submit the pre-authorization with completed information, meaning more back-and-forth was needed. The servicing provider lost a open slot that could have been used for other patients. Ron and Emily wasted part of their day waiting around for all of this to get completed.
Next Health Choice services remove the unknown variables and mitigate risk so that patient continuity of care is achieved, service providers are compensated accurately, and ordering providers take care of their patients. The Next Health Choice dashboard clearly shows patient status, and notifications keep everyone in the loop. This means we don’t let anything fall through the cracks.