For the novitiate seeking entry to the brave new world of Managed Care, the single most daunting challenge s/he will
confront sooner or later is what is known in the argot as The Referral/Authorization. Translation:
The process through which a patient gets a referral from the primary care physician to the specialist for a consultation or procedure. Sounds pretty straightforward doesn't it? Alas, nothing raises the blood pressure higher, nothing brings out the nasties quicker, and nothing produces such a heady rush of relief once successfully accomplished, as does this one little remarkable social transaction. Let us illustrate below with some typical scenarios.
Scene 1: Monday, 7:45 a.m Ms. M. calls. Receptionist picks up.Ms. M: Hi, this is Ms. M. I have an appointment at 8:30 with my eye doctor and they won't see me without a referral.
Receptionist: Did you call before to get a referral? Ms. M: Oh yes Dr.------- told me it was O.K. Receptionist:
But did you actually speak to anyone in the referral department about it? Ms. M: What referral department? Receptionist: What HMO are you in? Ms. M:
Aetna Receptionist: Well someone from the referral department has to know about it so they can get the information to Aetna. Otherwise your eye doctor won't get reimbursed. Ms. M:
Well why don't you do it? Receptionist: I can't. All my other lines are ringing. That's why we have a referral department. Ms. M:
Well can't you have them fax it when they come in? Receptionist:
I'll pass on the message to call you. They start at 9:30. And besides, they need all your insurance information, reason why you're seeing the eye doctor etc. Ms. M:
That's ridiculous. I can tell you right now. Why can't you give them the information? Receptionist:
I already told you. I have patients waiting to be helped on my other lines. Actually I have to get off this phone right now. Just give me your name and number and I'll have someone call you as soon as they come in. Ms M: Does this mean I have to miss my appointment? Receptionist:
No it doesn't. But next time, unless its an emergency or something came up unexpectedly, try to get the referral ahead of time. Ms. M: How am I supposed to know that? And the moral of that is….get to know how your insurance policy works as well as you get to know your new baby. Scene 2: Tuesday,10: 00 a.m Mr. Y calls. Receptionist answers.Receptionist:
Doctor's office. Can you hold please? Mr Y: NO!! I can't hold. This is an emergency. Receptionist: O.K. tell me the emergency. Mr. Y:
I need a prescription refill and I have to go out of town. I need you to call this number. My pharmacist says if you call this number I can get it and I won't have to pay $10 a pill. Receptionist:
What's the pill? Mr.Y: Viagra. Receptionist: What insurance do you have? Mr. Y: Oxford. Receptionist:
Oxford doesn't approve Viagra without asking a lot of questions. Mr.Y: So what's the problem? What do they want to know? That my wife's gonna divorce me? Receptionist:
I'll do what I can. But it might take at least three or four days. Mr. Y: Oh boy….. And the moral of that
is…..insurance companies were not created to make life easier or more fun for patients. Scene 3: Wednesday, 12 noon Ms. J. calls. Receptionist answers.MS. J: Hi, this is Ms. J. and don't put me on hold. I want to speak to a real person. Receptionist:
One moment ma'am. I'll pick up again as fast as I can. Ms. J: I want Monica. Receptionist: Who? Ms. J:
Monica. Or maybe its Miranda, Maria, Marilyn, somebody. Anybody. She called me back yesterday about a referral I asked for. Receptionist: D'you mean Maritza? Ms.J:
Yes thats it. Maritza. Receptionist: O.K. hold a moment until I can connect you. Maritza's on another call. Can you hold on a couple of minutes? Ms. J: O.K. I'll hold.
(Connection made to Maritza. Hooray.) Maritza: This is Maritza. How can I help you? Ms. J: Oh yes, I called you about a referral. Can you fax it right now? I can't wait three days or whatever it is your machine says you have to wait. Maritza:
What do you need the referral for? Ms. J: I have terrible back pain. Maritza: Who's your primary doctor? Ms. J: Dr. Yaffe. Maritza
: Has he seen you for this yet? Ms. J: Why do I have to see him? Maritza:
Because he might need to evaluate it first to see if we can help you here before sending you to a specialist. Ms.J:
I don't want to waste my time coming in if he's just going to send me to someone else. Maritza: Who's the doctor you want to see? Ms.J:
I don't remember his name but my friend goes to him and I have his fax number. Can you do it right now? And the moral of that is, when
you sign up for a managed care plan, don't be vague or impatient about answering questions that the staff ask you. Responses such as "Look up my chart" or "Call Directory Information" will only delay receiving the help
you need because they add to the total time a referral staff person has to take to get your referral processed.
Scene 4: Thursday, 3:00 p.m. Mr. W. calls. Receptionist answers.Mr. W: Hello, hello, I need a referral. Receptionist
: Just a moment sir. Mr. W: You have a terrible system here. I've left five messages and no one ever bothered to get back to me. Receptionist: Who did you leave the messages with?
Mr. W: I don't know. Somewhere on that menu list on your voice mail. Don't you keep a record of these things? Receptionist:
Alright sir, just be a little patient. Let me try and find someone who can help you. Mr.W: I've been nothing but patient. Your system is a disgrace. Receptionist:
I'm going to connect you to Fran. Mr.W: Fine. (Connection made to Fran.) Fran: Mr. W. I understand you called and left several previous messages? Mr.W:
I left them on the machine. (Fran calls over to Linda.) Fran: Linda did you retrieve a message from Mr. W? Linda: Yes, Maritza's working on it. Fran (to Mr. W):
Mr. W., someone's already working on getting you your referral. Mr.W: Oh yeah, but how soon does that mean I'll get it?. Can't you do it now that I've got you on the line? Fran:
Sir, two people working on the same referral won't make it happen any faster. Besides, I have someone standing at my window right now who's already waited ten minutes to be helped. And that was before they put your call through to me.
Mr.W: This whole referral thing's a pain in the ass. When is this Maritza going to call me? Fran:
As soon as she gets off the phone with the insurance company. She's waiting for a pre-authorization number. And the moral of that is we
do understand your desperation when you call for a referral and get nothing but a disembodied voice telling you to press numbers on your telephone key pad (especially when your cell phone batteries are running low).
Nonetheless, telling your tale to anyone who'll listen, even a computer voice, only means that now two or more people are going to be mobilized into getting your referral done and someone else will have to wait even
longer to get theirs. Scene 5: Friday,4:45 p.m.
Ms. T. calls. Receptionist answers.Ms.T: Hello, who's this? Receptionist: Sandra. Ms.T:
Oh hello Sandra. I'm here at the radiologist's office waiting to get an MRI but they won't do it because your referral department didn't send an authorization number. Receptionist: An MRI of what? Ms.T: I don't know. Isn't it in my chart? Receptionist: Ma'am you only just called. Your chart isn't in front of me. Ms.T:
You mean to say you can't find my file? Receptionist:
No ma'am. I don't mean it's lost. I just mean I can't leave the desk right now to go pull out your file and there's no one in the chart room at the moment who can get it for me. Ms.T:
Well the doctor knows what I'm getting. Just ask him. Receptionist: The doctor's doing a procedure and I can't interrupt him. Ms.T: Put me through to your referral person. Receptionist: Fine, I'll connect you to Fran. (Connects to Fran.) Fran: Ms. T. I understand you're in the radiologist's office waiting to get an MRI. Ms. T: Oh brother. Fran: You can't get an MRI without pre-certification. Ms. T: But I thought all that was already taken care of. That's why I'm here. Fran:
You can't get an MRI approved without prior authorization. Ms. T: The doctor approved it. Fran:
That makes no difference. Oxford has to approve it. You'll need to answer some questions for medical review by an Oxford physician before they'll approve it. Ms.T: Why? Fran:
Because those are the rules. MRIs are very expensive and they want to make absolutely sure your primary physician had a good reason for ordering one. MsT:
Well I left the paper on which he wrote the diagnosis at home. Fran: Then you'll have to wait for me to call you back after I speak to the doctor. Ms.T: Then what?
Fran: Then I call Oxford and wait for them to call me back with a pre-certification number. Ms.T: How long will that take? Fran: Anywhere from two to twenty-four hours. Ms.T: You've gotta be kidding. I'm already sitting here. Fran:
I'm really sorry but there's nothing I can do. They won't do it until you get approved, because if you're not approved they won't get paid. Ms.T:
I wish we were back in the old days and you didn't need all this. Fran: I know you do. So do we. (Two hours later.) Fran (calling Ms.T. back):
Hi, Ms. T. This is Fran. Good news. I got approval for an MRI of the abdomen. Don't worry, Dr. Yaffe said that was the one he wanted. Your authorization number is------- (Happy ending. Cheers all around.)
And the moral of that is, following rules of protocol, communicating clearly and, yet again, thoroughly understanding what your insurance coverage
allows, makes even Managed Care a less bitter pill to swallow. The point of the above dramatizations is this: all scenarios were actual conversations
between patients and staff that have been transcribed verbatim. The only thing remarkable about them is in the numbers. Consider the following: each transaction takes anywhere from 10 minutes to 2 hours to complete. If
you allow 20 minutes as the average per referral and multiply that 20 by the number of referral/authorization requests we get on a daily basis (between 75 and 100) the total time spent only on processing referrals
comes to about 1740 minutes or 29 hours per day. That, divided between 4 full-time referral staff, averages out to 7 hours 15 minutes a day per person if they were to work straight through without a single break!
And that, dear reader, is what we will leave you to contemplate in our March issue of The Chronicles. |
