Electronic referrals and precertifications at your fingertips

Nov. 1, 2010

A multi-payer portal empowers administrative staff to improve care coordination.

Referral and authorization processes are a key part of the day-to-day operations of any primary-care physician or specialist office. While these processes are often viewed as administrative necessities, they are also very important pieces of the care coordination continuum. By arming administrative staff with online tools to make these processes quick and easy, a physician practice can empower staff members to improve care delivery and patient service.New Jersey-based Berlin Medical Associates (BMA) is a multi-specialty practice with eight providers treating more than 250 patients a day. The practice offers a comprehensive approach to the diagnosis, treatment and management of both the individual patient and the family, delivering a full range of services to its patients.

In specialty practices, most patients need referrals prior to treatment, and managing those referrals is especially time consuming. The administrative staff at BMA found the process of verifying referrals to be inefficient and labor intensive, often requiring staff to look up primary-care physician information in a phone book and log calls to insurers and other offices. A single referral verification could take up to 15 minutes to complete. Additionally, because many referrals received were handwritten, the paper clutter began to accumulate in patients' files, taking up a large amount of the limited office storage space. As the practice continued to grow, staff knew they needed to find a quicker, more efficient way of navigating the referral process, or they would end up buried in paperwork and overloaded by phone calls, unable to provide their patients with the quality of care and attention they deserve.
To address the challenges of obtaining and verifying referrals, BMA began using NaviNet, a healthcare communications network that enables practices to securely connect electronically with health insurers that cover their patients. NaviNet Insurer Connect is offered by health insurers at no cost to providers and enables BMA to communicate with several insurers from a single Web site. Using this system, BMA is able to connect with Aetna, AmeriHealth Mercy and Horizon Blue Cross Blue Shield of New Jersey. BMA staff can search for the status of referrals and quickly determine if the insurer has authorized care even before the patient comes to the office for an appointment.
“With electronic access to our patients' insurers, obtaining referrals is dramatically quicker and easier,” says Jeanne Rosser, office administrator at BMA. “We eliminated the need to find patients' files, look up primary-care physician and insurer information, and manually make calls for verification. The entire process now takes less than two minutes per referral. We complete between 40 to 50 referrals daily and always have at least one person using NaviNet.” In the practice, referrals that would have taken between 10 and 12.5 hours each day can now be completed in less than two hours.

Real-time access to patient information also improves the practice's patient relations; BMA is able to look up patients' insurance eligibility and benefits, and to receive care authorizations (precertifications). The practice enters precertifications online, in addition to checking whether a service needs to be precertified. Since the practice conducts many specialized tests and treatments that can often be costly, the staff can determine if a patient is covered by insurance and how before providing care. “Knowing what type of insurance a patient has in advance of the appointment ensures that patients won't get hit with a big bill for service that wasn't covered by their insurance, improving the patient experience,” Rosser says.
BMA can now provide patients with written documentation from an insurer with an explanation of coverage and/or reasons for denials or changes of a procedure. This results in more thorough conversations about care delivery. Further, having a record of all referrals along with up-to-date insurance information validates the need for the care provided. “If a patient is denied coverage, our administrators have the information they need to act as an advocate for their patients and communicate with the insurer about the denied claim,” says Rosser.

The benefits BMA has seen include cost savings, time savings and improved patient relationships. “If our practice didn't have NaviNet, we would have to employ another full-time administrator to process referrals manually,” Rosser says. “It has become a critical part of our daily
work flow.”.

Peggy Denness is director of provider advocacy, NaviNet.
For more information on NaviNet solutions:

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