Prior authorizations are placing patients at risk and driving up costs in the acute care setting including the additional pressure on hospitals delaying discharges, increased length of stay for patients waiting for placement and adding additional strain to the staffing shortages of nurses to care for these patients. The case manager's workflow has also been affected by the delays in the progression of care of patients ready for post-acute placement. We are now spending countless hours contacting the SNF and/ or payer to learn if authorization has been obtained. So, what are we up against and what can be done to affect change? How can we be better advocates for the patients and work to move them to the next level of care more efficiently to open our beds for patients in acute need?
Many commercial payers have policies in place that allow them 24-72 hours to review a request for placement at the next level of care following hospitalization. To complicate and delay this process further, hospitals cannot seek authorization until a discharge order is present. So, the ability to be proactive and refer a patient who is known to require post-acute placement is delayed until the patient is near or at their discharge date. Due to this “rule,” a timeline now looks like this:
The physicians state the patient is ready for discharge on a Friday, which is day 3 of their stay. The case manager receives this information in rounds at 10, meets with the patient for choice and has packets sent for placement. The post-acute facility requests authorization on Thursday afternoon. The clock will now begin but the 72-authorization process only applies to weekdays because the payer isn’t likely open on Saturdays and Sundays. Now, 72 hours has turned into 120 hours and a patient who was ready for discharge on Thursday will now likely discharge on Tuesday.
To be proactive, discuss choice as early in advance as possible with the patient or family. Therapy will likely recommend placement prior to the discharge date. Have those conversations with the patient to give them time to review facilities and make a choice. Once the patent is near discharge, you will be able to send packets immediately without delay. In cases where you may receive a denial for an appropriate placement, have the patient place an appeal with their payer. Patient appeals have been very effective in being overturned. Depending on the payer, they likely have a process/ form that the patient can complete immediately upon denial to appeal.
While all of this is going on with one patient, you still have another 18-24 patients to screen and assess! Case managers are so busy but also important to remember to reevaluate the discharging patient for the level of care you are placing them in. Have they progressed and can now go home? If you are waiting on authorization and the patient is now in the appeal phase for placement, it has likely been at least 3-5 days since this patient required this level of care. Do they still require this level of care? What can we be doing during that time to get them home or to be safe with a lower level of care?
- Could they have dressing change education and training to go home?
- Could therapy work with the family and the patient for transfer and mobility safety to go home and have outpatient therapy?
- Have they improved enough while waiting for auth that they no longer require that level of care?
- Would home health or a paramedicine or mobile medicine program be able to meet their needs at home?
Placement challenges continue to plague us and there is no light at the end of this tunnel other than to be more proactive, be persistent with the payers and involve the patient and family in the process as appropriate. Use your case management assistants to keep up on the logistics of placement and contact with the payers for authorization and acceptance of the patient. Use your multidisciplinary team to continue to work towards a discharge plan for the patient if placement cannot occur at the level of care you are requesting. Case managers are tenacious multitaskers and advocates for the patient. It is going to take all our skills and tenacity to face these continued challenges.
Bio: Marie is the Chief Operating Officer of Phoenix Medical Management, Inc., the leading case management firm. Marie has practiced as a nurse for the past 25 years with 17 years in the field of case management. Marie has served in several roles in Senior Leadership roles in Case Management. She has had leadership oversight including case management, utilization review, denials prevention, clinical documentation improvement, and medical record integrity. Marie has authored articles for RACmonitor, CMSA, and Case Management monthly. She is also a weekly contributor on Finally Friday and is a Board Member for the Arizona ACMA. Marie holds an MBA from the University of Phoenix and an MSN in Leadership from Grand Canyon University. She received her Bachelor of Science in Nursing from Northern Arizona University.
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