Published in: NAHAM Connections

Author: Jennifer Glockzin, Senior Manager – Patient Access

The intention to provide swift and effective patient care often leads to misconceptions among clinicians and prior authorization teams. One common misunderstanding is marking medical orders as stat or urgent will expedite patient care, which is not always the case, particularly in the realm of insurance processing.

Misconceptions and Realities of Stat Orders

Many providers operate under the assumption that labeling an order as stat will lead to quicker insurance approvals, especially in critical cases like cancer. However, insurance companies typically process such stat requests within a two to seven business day window. They argue that a short delay in processing authorizations for conditions such as cancer won’t significantly alter the prognosis. This often leaves patients anxious and providers frustrated, particularly when the perceived urgency isn’t met with the expected response from insurers.

The Financial and Emotional Impact on Patients

This process becomes even more strained when patients receive the initial bills directly because the tests were marked as urgent without confirmed coverage. For instance, patients might find themselves facing a $12,000 bill for a positron emission tomography (PET) scan that was ordered stat but not approved in time by insurance. This not only escalates financial stress but also creates tension among patients, facilities and providers who end up in a triangular blame game with the insurance companies.

Strategies for Provider Education and Advocacy

  1. Understanding Insurance Processes: It’s crucial for providers to have a clear understanding of how insurance companies handle stat orders. Education on the typical timelines and requirements can prevent unnecessary urgencies that lead to patient distress and financial burdens.
  2. Communication and Documentation: Providers and their staff should ensure that all necessary documentation and justifications are thoroughly prepared when submitting authorization requests. This can help in reducing denials or delays based on inadequate information.
  3. Collaborative Advocacy: Providers and healthcare organizations need to unite in their advocacy efforts against cumbersome insurance practices. Engaging with organizations like CMS to push for policy changes that expedite care without compromising on procedures is essential.
  4. Contract Negotiations: Leveraging contract negotiations with health plans can also be a strategic approach. Providers can argue for faster turnaround times on authorizations, reflecting their commitment to timely patient care.
  5. Educating Patients: Informing patients about how health insurance works, including the intricacies of stat orders and prior authorizations, can empower them to be more understanding and proactive about their care plans.
  6. Team Coordination: It’s vital for healthcare providers to ensure that their administrative and prior authorization teams are well informed and equipped to handle these issues. Regular training sessions and updates on insurance policies can help streamline the process.

Real-life Implications and Long-term Solutions

Providers often find themselves in a predicament where, despite urgent medical needs — like a patient requiring immediate surgery for a ruptured disc — they are compelled to follow insurance-mandated procedures such as conservative therapies that may not be immediately beneficial. To address this there needs to be a system where providers can contest such mandates effectively based on medical necessity.

Moreover, the challenges do not end after obtaining initial authorizations. Surgical procedures often reveal additional issues that were not visible in initial assessments, leading to the need for more extensive interventions than previously authorized. This necessitates a quick reauthorization process to avoid patient liabilities for unforeseen surgical expenses.

While the intent to expedite patient care is commendable, the lack of understanding and coordination with insurance protocols can adversely affect patients both emotionally and financially. Office administrators and prior authorization teams must work closely to educate providers on the implications of stat orders, improve communication channels and advocate for more rational insurance practices. Through a concerted effort, it’s possible to achieve a balance between prompt patient care and manageable healthcare costs.

With extensive experience in every aspect of a clinical office, Jennifer Glockzin has honed a comprehensive understanding of the roles and responsibilities of medical office staff. Glockzin has worked at the front desk, served as a medical assistant and has held positions as a surgical coordinator and clinical coordinator. This diverse background has helped her gain a deep insight into the challenges and tasks each employee faces. Glockzin leverages this vast experience to mentor clinical staff, helping them gain valuable experience and streamline their workflow, ultimately making their responsibilities more manageable. With excellent communication skills, she bridges the gap between employees and management, fostering a collaborative and efficient work environment.