Pre-authorization position.

46oldnewrn · Nov 10, 2011

What skill? You need to give more details.

roser13, ASN, RN · Nov 11, 2011

Agreed, need more details. Do you mean with an insurance company?

Been there,done that, ASN, RN · Nov 11, 2011

Sorry, yes with a very large HMO.

CapeCodMermaid, RN · Nov 11, 2011

I don't think your background has as much to do with your capability to do this job as does your understanding of the insured's coverage. Each company and each plan within that company has many different levels of coverage.

nulife4good · Nov 11, 2011

Worked for HealthNet and Anthem Blue Cross for 10+ years, (worked as a corporate trainer for licensed and non-licensed staff) before switching to nursing recently. I worked and trained reps for Pharmacy business management, case management, utilization review, care coordination, customer service, and admissions.

I'm assuming that you're dealing with requests for medical admissions. The majority of these review type positions involve the application of decision trees and boolean models in order to determine the approval or denial of certain services. Based on what you're doing, you'll probably be at a desk with a huge binder listing various insurance benefits that you'll refer to on a case by case basis. Although some of these reviewer positions require some creative thinking, the majority of them (based on my experience) involve following a specific protocol in order to meet various state policies and procedures.

diva rn, BSN, RN · Nov 11, 2011

I only have an Associate's degree.. but many years of experience in many areas.
I will be started a pre-authorization position on Monday.
I would appreciate any advice on how I can learn this skill . I understand I will be using Interqual, talking to many disciplines and applying the correct placement and level of care for patients.
Please share your expertise with me.

This is what I do now..I work for a private company that does medical review for 80 different labor unions insurance funds all across the country. They are all self insured but use BC/BS for their PPO networks. So this is EXACTLY what I do..We preauthorize everything from tests, in and out patient surgery, home health, physical therapy, durable medical equipment, rehab, snf and psych. I have authorized everything from a removal of a wart to a heart transplant!!! Nothing is too little or too big...we also follow inpatient hospital stays with case management and utilization review and monitor for compliance. Then follow the pts thru home care, pt etc....I take in at least 25 new cases a day...and I speak to another 50 or more people who call in...and I have a 4 page list of cases I am working on...it's very, very, very busy...

It is not a skill...at all..it is something that you have developed (hopefully) from working-and the more years and in the more areas the better..it really isn't something you can learn..other than learning the specifics of the way that company does them...

the way my company works is..the MD's office, or hospital will call in to precert a procedure ...I gather the clinical information and review it to make sure it meets medical necessity....if I am not absolutely sure about something, I send it to one of our MD reviewers and let him/her make the call before I authorize it...or deny it....

We do not have any CHARTS or TREES....to follow...I don't know where that idea came from (in another post)..and we don't have any manuals to use...either...JUST medical knowlege and common sense...

Your years of experience will serve you well...you don't need more than an associates degree...not important for this job...

as far as insurance knowlege goes, that's going to depend on who you are working for...I don't need to know anything other than what MY unions want...and on that I am an expert...so you don't need to be an expert on the insurance field if you get the plans down pat that you represent...

Do not worry...it's common sense and your medical knowlege...you will do fine...:)

vanburbian · Nov 11, 2011

I can add to posts above...I actually left a job doing exactly as above, pre authorizing services and also following patients who were already admitted, which is known generally as "concurrent" review.

We did use InterQual, but because we also managed Medicaid and Medicare eligible patients, some procedures did have to meet certain guidelines, which you determine, based on medical necessity.

The first determination you make is whether or not it is a covered service, for example- gastric bypass.

The second is, if it is covered, are there guidelines and criteria that must be met, for example- in gastric bypass, is the BMI high enough? Did the pt. attend the prerequisite educational, nutritional and counseling classes prior to scheduling the surgery?

Are there any contra indications that could be a hard stop, such as an organ recipient, a history of active drug and or alcohol abuse/dependence, etc.

Then you see if the service is provided by the right type of provider, at the correct facility (all based on any particular insurers panel and individual rules).

So, ok....it's covered, and they appear to meet all the criteria. Then you approve it. If it's not covered, you deny it.

If they meet some criteria, you let the person sending info and request in know you need x y or z....

Then you may give it to a medical director/physician adviser for their determination, or you approve or deny based on the benefit, and the standard criteria.

Most insurance plans model their services based on Medicare and CMS guidelines.

For the most part, it's simple stuff. MRI requested, and they haven't even had an xray for their knee pain. Well, ins co mandates the xray be done first.

Those are the "trees" that are meant.

Good luck, get used to being yelled at for denying services that are not covered, and for needing for than 5 minutes to give someone an answer.

nulife4good · Nov 11, 2011

diva rn, I gave a generalized response to the original poster's response. The decision tree that I was referring to was often used for my non-licensed staff something along the lines of "if the patient hasn't used this medical equipment product, then suggest the following_____________" not alot of creative thinking involved.

Within the company I worked in, the clinical reviewers followed specific protocol in order to provide authorization. Within that protocol, they were given "wiggle room" in order to make a determination based on a case by case basis. When I use the phrase "clinical reviewers" this is an umbrella term for those associates who carried varying degrees of medical licenses regardless of whether the position required an AA, BS, etc. What some of them discovered is that they didn't like the lack of autonomy that came with the position and quickly became jaded with the process.

Another poster addressed the frustration of having to resolve calls within a specific amount of time and dealing with upset callers. These were some of the downsides to this position. But, you can't beat sitting at a desk, wearing your own clothes vs scrubs, having a set schedule, and not working on the holidays

diva rn, BSN, RN · Nov 12, 2011

Nulife....yeah, I got you...we don't follow a formal protocol tree but I know what you are talking about. Our company is much smaller than, say UHS, and only the RN's make the decisions to preauth or not...we have techs that are medical assistants who can start the files and call out to the MD offices and ask for the clinical info to be faxed or whatnot, but only the RN's can enter the info and auth. And of course, hopefully we know enough to not preauth an arthroplasty (or brain surgery) without the guy having had imaging, etc. Also follow UR in the hospital...blah, blah....

I had to laugh out loud about the "get used to being yelled at" for not having things done...I understand....however, we have a loophole..on the back of our insured's cards it clearly states to call the procedures in at least 7 days in advance..and when they start to get snotty with me, I politely remind them that "poor planning on their part, does not constitute an emergency on my part"...and since I hold the cards..or the power to hit the "alt-Z" key (that sends the auth)...they settle down pretty quick and usually apologize...................:)

It's an OK gig...I really miss ICU for a lot of reasons though...mainly because I am such a night owl...I miss my 7p-7a shifts doing 3 12's a week...I hate doing 5 days a week...but it is nice to sit on my butt all day..in airconditioning...and not wear makeup...we all wear jeans and whatever we want..now it's football season..so everyone is representing!

RN In FL · Nov 12, 2011

Hey everybody, I just want to add, I worked for Aetna, Inc for 10+ years. When the RN's were unable to approve procedures ( breast reductions, gastric bypass surgeries, abdominoplasties, uppp's, hernia repairs), based on our criteria, they they were refered on to the medical director for review. We had to send all of the info we gathered, (photo's, documented failed diet plans, sleep study, lack of tolerance of cpap, etc) The job requires total organization in order to meet deadlines and turn around times. I totally enjoyed it. Good luck!!

diva rn, BSN, RN · Nov 12, 2011

Hey everybody, I just want to add, I worked for Aetna, Inc for 10+ years. When the RN's were unable to approve procedures ( breast reductions, gastric bypass surgeries, abdominoplasties, uppp's, hernia repairs), based on our criteria, they they were refered on to the medical director for review. We had to send all of the info we gathered, (photo's, documented failed diet plans, sleep study, lack of tolerance of cpap, etc) The job requires total organization in order to meet deadlines and turn around times. I totally enjoyed it. Good luck!!

Yes, although we have some criteria in place that allows me to authorize breast reductions, gastric bypasses (for those funds still allowing that procedure) and all hernias without sending out to our medical reviewers...the uppp's..no, those always go....also those cheesy dental appliances-when the patients don't want to wear the cpap machines and they read on the internet (usually on web site called something like "I hate cpap.com"..) about these things..I have to get all of that going and send that out and prove they can not wear the cpap...the funds will usually pay for one or the other not both...as far as the requests for the "iffy" stuff...we sure as heck tell them when they call in that it' is better to make the DOS TBA...as we can not control our medical reviewer and the turn around times...usually pretty fast...but better to be safe than sorry...also for the blephs...

My "favorite" call is to take in a case for something like a uppp and the surgery is the next day.....I'm like, REALLY? Especially with really weak clinical...you know what I mean... ..um, "she snores"..ok, what else...that's it....yes, good luck.............................