Every hospital or physicians practice focus should be on the front end, so you don’t have to pick up the pieces later for incorrect billing, appeals, self-pay collections, and bad debt just to name a few. Your organization loses a lot of money working accounts on the tail end when just a little more effort up front would resolve most of your revenue cycle issues.
All information obtained by central scheduling from any physician’s office or referral source must be accurate and verified as such. You should create a hospital form if you don’t already have one for all of your providers. I know they want to use their own but really when you think about it the information will be used in your facility or practice so it should make your process easier. I’m attaching a sample form:
Phone: Logo Fax:
PRE-AUTHORIZATION INFORMATION FORM
HEALTH PLAN/Payer __________________________ Pre-Auth Phone #_______________________________
Date: ______________ Requestor’s Name: _________________________ Phone #: ________________________
Fax #: _________________ Tax ID #: ___________________________ CMO #: ___________________________
PCP, Phone and ID #:__________________________________________________________
Requesting Specialist and ID #: ___________________________________________________________
Member ID #: _________________________________Proposed Date of Service: __________________________
Patient Name: ________________________________ DOB: _________Social Security #: ___________________
Patient Address: __________________________________ Patient Phone Number: _______________________
(Please provide a current copy of the patient’s driver’s license, front and back of the patient’s insurance card(s) and demographic form, if available)
Provider Name/Physicians Name: ____________________________________________________________
Physicians Address: ____________________________________________________________
Inpat. ___ 23 Hr. Obs. ___ Outpat. ____ Surgery ___ Radiology ___ Wound Care ___ Sleep ___ PT/OT/ST ___
Diagnosis: _______________________________________________________ ICD 9 Code(s) _______________
Procedure _____________________________________ Outpatient Procedure Code(s) (CPT4): ________________
Describe specialist services requested and number of visits authorized: ____________________________________
Please submit clinical history (signs/symptoms, tests, previous treatment, and/or progress notes for ALL pre-authorization requests).
Please describe, if applicable, any special circumstances which (which includes but is not limited to disability, acute condition or life-threatening illness) may require flexibility in the application of screening criteria: ____________________________________________________________
Pre-authorization number: _____________________
Referral number: _____________________________
You can place this on your website they can fax it or email it to you. Make it convenient for them.
Don’t be afraid to use your information systems scheduling module if you have one. I’ve seen too many facilities and practices not use a piece of their information system because they didn’t understand it or it seemed too cumbersome to use.
During the scheduling process you need to ensure the patient knows:
1. What the costs are for their service, procedure or test?
2. What they have to pay at the time of their service, procedure or test after you verify and pre-certify their insurance?
3. What they have to bring with them?
4. What are the requirements for my procedure, no water for 24 hours, no food, etc.?
5. How long their service, test or procedure will take?
6. Any other pertinent information, physician’s instructions, special instructions, etc.?
7. Finally PRE-REGISTER the patient. It saves time for everyone when the patient arrives at your facility or practice.
During the scheduling process you need to ensure the physician or referral source knows:
1. Time and date of the service, procedure or test?
2. If any of the insurance or demographic information has changed for the patient?
3. Of course after the service, test or procedure, the results.
Referral, Notification and Pre-Certification
Most health maintenance organizations (HMOs) and point-of-service (POS) plans require a referral, notification and/or pre-certification from the patient’s primary care physician (PCP) or specialty care physician (SPC) before they obtain services from a facility or practice. If they do not obtain the necessary approvals, the insurance plan may not provide coverage and the patient may be responsible for the full cost of these services. Therefore referrals, notifications and pre-certifications are vital to your revenue cycle and overall financial stability. Verify all patient insurance information prior to any service, test or procedure and notify the physician’s office of any required referrals or pre-certifications that aren’t already present at the time of scheduling.
It’s up to you to get it right up-front!
If you would like any further information about this article, revenue cycle services, revenue cycle management or a copy of the form in this article please contact Lynn J. Cheramie III, Owner, www.compasshealthsystems.biz at 1-800-597-1066.
Next Up: Revenue Cycle Management and Services, Part 4, Charge Capture.