Ensuring patients receive the care they need while navigating the intricacies of insurance requirements and prior authorizations can be a daunting task. In this interview, Monique Ontiveros a prior authorization manager, and Shellie Nichols, a prior authorization specialist, discuss the complexities and best practices in Patient Access, with a focus on the prior authorization process.
With decades of combined experience in healthcare, patient access and prior authorization specialists Monique Ontiveros and Shellie Nichols, share their insights, offer practical tips and discuss how patient access professionals can improve operations in their practices.
Can you share a bit about your background and what inspired you to pursue roles in Patient Access, particularly within the realm of prior authorizations?
Monique Ontiveros (MO): I started at Infinx two years ago as a prior authorization specialist, and I’m now the manager of the prior authorization department. My journey in healthcare began about 20 years ago, working in the front office at various doctors’ offices. I’ve worked in specialties ranging from internal medicine to orthopedic surgery. I eventually transitioned to a more administrative role, which led me back into prior authorizations and ultimately to Infinx.
Shellie Nichols (SN): I’ve been with Infinx for three years as a prior authorization specialist, but I’ve spent over 20 years in healthcare. I started as a medical assistant and was on track to become a nurse, but I discovered my knack for understanding insurance requirements and getting authorizations approved. My clinical background gives me a unique perspective, allowing me to advocate effectively for patients in my current role.
What are some of the most common challenges you see in Patient Access, particularly related to prior authorizations?
MO: One major challenge is the domino effect that occurs when there’s a lack of attention to detail during patient registration. If patient information is incorrect — like a wrong date of birth or an outdated insurance number — it can lead to significant issues down the line, including denied claims. These problems often stem from the front desk and can affect the entire process, including prior authorizations.
SN: I completely agree with Monique. Another common issue is when patients’ insurance information isn’t updated regularly. For example, a patient might come in for a treatment with insurance that lapsed or changed, and we wouldn’t know until it’s too late. This can cause major disruptions, especially if prior authorizations were already processed based on outdated information.
Takeaway: Prioritize attention to detail in front desk operations by ensuring accurate patient registration and consistent verification processes.
What practical solutions do you recommend for addressing these challenges?
SN: It may seem straightforward, but one of the best practices is to consistently verify patient information at every visit. Even if a patient says their insurance hasn’t changed, it’s important to double check. Always ask for the insurance card and scan it into the system. Making this a standard practice can help prevent issues down the line.
MO: Implementing a system where front desk staff are trained to ask the right questions every time can lead to significant improvements. For instance, rather than asking, “Is everything the same?” which often leads to a “yes” answer without much thought, they should directly ask for the insurance card and any updated information. Consistency and accuracy at the front desk are key to preventing downstream issues.
Takeaway: Curiosity and Learning:
- Advocacy Through Expertise: Shellie highlighted how her role has evolved from a clinical background to becoming an advocate for patients through the prior authorization process. Her ability to navigate insurance requirements ensures that patients receive the necessary approvals for their treatments.
- Continuous Learning: Both Monique and Shellie emphasized the importance of staying informed about the specialties they support. Understanding medical terminology and the specifics of different procedures allows them to better advocate for patients during the authorization process.
You mentioned that you’ve had some recent successes in improving operations for your clients. Could you share an example?
MO: We recently worked with a client who had a significant backlog of around 800 prior authorization cases. There was no clear process or workflow, which created a lot of chaos. Shellie took the initiative to create a comprehensive listing of all the payers, their contact details, portals and specific requirements for prior authorizations. This tool became a game-changer for the team, helping to streamline the process and reduce the backlog.
SN: Yes, once we had everything organized and in one place, the team could work more efficiently. We went from dealing with a chaotic workflow to having a structured process where everyone was on the same page. This not only improved our turnaround times but also enhanced the clients’ satisfaction with our services.
Takeaway: Collaboration and Communication: The experts pointed out the necessity of maintaining clear communication within teams. When new information is obtained about a payer or process, it should be shared with the entire team to ensure everyone is on the same page.
In your experience, how does automation fit into the prior authorization process?
MO: Automation plays a crucial role in streamlining the prior authorization process by handling repetitive tasks, reducing the time spent on manual data entry and ensuring that routine steps are completed efficiently. However, while automation greatly enhances our workflow, it’s important to remember that it works best when combined with human expertise. In complex cases, the critical thinking and decision-making skills of our team are essential to ensure that everything runs smoothly.
SN: For example, automation can take care of initial data gathering and verification, which speeds up the process and minimizes the risk of errors. However, when dealing with nuanced decisions or unique cases, our experience and judgment are crucial. It’s about striking a balance — leveraging technology to enhance efficiency while also utilizing human insight to ensure accuracy.
Takeaway: Balance Automation With Human Expertise: Using automation for data gathering boosts efficiency and reduces errors, while human expertise is essential for nuanced decisions to ensure accurate and compassionate patient care. Balancing both is crucial for optimizing the Patient Access process.
What advice would you give to other Patient Access professionals who are dealing with similar challenges?
MO: My advice would be to stay organized and ensure that you have reliable reference tools like the spreadsheet Shellie created. Keeping detailed records of payer requirements and regularly updating your knowledge of medical terminology can go a long way in making the prior authorization process smoother.
SN: I would emphasize that communication within your team is essential. Ensure that any new information is shared with everyone, so that the entire team stays aligned. Additionally, always verify patient information and be familiar with the specifics of the CPT codes and insurance criteria you’re dealing with. This attention to detail can prevent many of the common issues we encounter.
Wrap-up: 4 Practical Tips for Patient Access Professionals:
- Always Verify: Don’t assume patient information is unchanged. Always ask for updated insurance and contact details.
- Document Everything: Keep meticulous records, whether it’s tracking payer requirements or noting specific criteria for authorizations. This documentation can save time and prevent errors.
- Stay Informed: Regularly update your knowledge of medical terminology and the specific criteria for the procedures you handle. This will enable you to advocate more effectively for patient authorizations.
- Communicate: Ensure that your team shares new information and maintains consistent processes. This prevents discrepancies and ensures a smoother workflow.
The work of Patient Access professionals is critical to the smooth operation of healthcare organizations and the well-being of patients. By focusing on attention to detail, consistent verification and collaboration, professionals can ensure that patients receive the care they need without unnecessary delays.
