DMHC APL Updated Advisory – Provider Feedback Requested

Dear Provider Members,

Our office has been actively pursuing the resolution of claims on your behalf for post-stabilization care and services that we believe have been improperly denied by health plans. After recent discussions with the Department of Managed Health Care (DMHC), we wanted to inform you of the below potential regulatory issues/legal interpretations that may impact your workflow and revenue capture. At this time, we ask that you please carefully review this notice and provide any input you may have, so that we can relay your concerns to the DMHC.

I. DURING POST-STABILIZATION AUTHORIZATION REQUEST PHONE CALLS, PROVIDERS SHOULD DOCUMENT THE (1) SPECIFIC SERVICES REQUESTED, AND (2) LENGTH OF SERVICE REQUESTED

At this time, we would request your input and feedback on the feasibility of implementing such protocols and how you can foresee these measures affecting your workflow. Some questions that you should consider when thinking about potential issues include: 

1) How often are you able to determine what specific services are needed and the length of stay at the time of an authorization request phone call? 

2) Is it customary for you to specifically request the above details?

3) Are there any barriers, medical or otherwise, to determining these details (e.g. what specific service is needed after stabilization of an enrollee’s emergency medical condition, along with the frequency of days that need approval?

4) Do health plans ask for or consider these details during the phone call?

NOTE: If you can supplement (or document) your answers with any examples of plans not responding to your authorization request timely after providing the above details, that would be extremely helpful to our advocacy efforts.

II. PLANS MAY NOT HAVE ANY RESPONSIBILITY TO ASSUME CARE IF THE PROVIDER LATER REQUESTS CONTINUED POST-STABILIZATION AUTHORIZATION

QUESTION POSED TO THE DMHC: Provider requests five days of inpatient admission following ER stabilization. Plan approves three days. On the third day, provider requests an additional two days for continued admission, but the plan denies or is non-responsive. Is there a responsibility to assume care at that point?

DMHC RESPONSE: The DMHC has taken the preliminary position that the assumption of care requirement only occurs upon the initial telephone call/contact requesting post-stabilization authorization. At this time, we would like to hear your thoughts about the DMHC’s position and whether you think it is appropriate or reasonable. Some questions that you should consider when thinking about potential issues include:

1) Are there scenarios where the patient could not be stabilized before admission and thus, more than one call is made (i.e., one for admission, one for post-stabilization authorization)? 

2) Are there medical examples/conditions where continued authorization requests are routine?

3) How often do payors underestimate or overestimate the length of stay required?

4) Do certain payors always provide authorizations for days-at-a-time (thereby requiring continued authorization requests) regardless of the severity of the medical condition? 

NOTE: If you can supplement (or document) your answers with any examples of plan behavior listed above, that would be extremely helpful to our advocacy efforts.

We look forward to hearing from you regarding any concerns/feedback/comments you may have.

Categorised in: Member Advisories

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