Prior Authorization

Summary

Vertusa's prior authorization solution streamlines the complex and time-consuming healthcare authorization process. It features six interconnected modules—Intake, Admin Review, Clinical Review, Peer-to-Peer Review, Correspondence, and External Entity Review—that simplify workflows and improve operational efficiency. Key benefits include intuitive UI, integration with member and provider databases, automatic approval/denial correspondence, and tools like the Duplicate Checker and Peer-to-Peer Review. The solution also manages admission scenarios, from pre-certification to discharge, ensuring smooth transitions and enhancing the overall healthcare experience for both providers and patients.

Takeaways

• 😀 Vertusa's Prior Authorization Solution simplifies and streamlines the complex prior authorization process, making it more efficient for healthcare providers and patients.
• 😀 The solution includes six interconnected modules: Intake, Admin Review, Clinical Review, Peer-to-Peer Review, Correspondence, and External Entity Review.
• 😀 The Intake module features an intuitive user interface that simplifies authorization requests for outpatient services, durable medical equipment, pharmacy, and more.
• 😀 The solution supports both in-network and out-of-network providers by integrating member and provider databases for verification, including handling ICD-11, CPT, and HCPCS codes.
• 😀 A Duplicate Checker in the Intake module helps prevent the creation of similar cases, improving operational efficiency.
• 😀 Admin Review ensures the correct clinical documents are submitted, with a document checklist and upload feature to streamline the process.
• 😀 Clinical Review by registered nurses incorporates clinical guidelines and easy access to case facts, reports, and diagnosis/procedure information to ensure accurate review.
• 😀 The Peer-to-Peer Review module allows for meetings between the medical director and the care provider to resolve disputes over denials, with calendar availability and notes features.
• 😀 Once a case is approved or denied, automatic correspondence is sent to concerned parties, improving communication and reducing manual effort.
• 😀 The Admission scenario is handled with a comprehensive approach, from pre-certification to discharge, covering the entire patient journey and ensuring smooth transitions and documentation.
• 😀 The solution automates the creation of inpatient cases post-admission and offers a discharge summary, ensuring a smooth process for the patient and clear documentation for the healthcare provider.

Q & A

What is the main purpose of Vertusa's Prior Authorization solution?

The main purpose of Vertusa's Prior Authorization solution is to streamline and simplify the complex, time-consuming prior authorization process in healthcare, making it more efficient for healthcare providers and less burdensome for patients.

What are the six interconnected modules in Vertusa's solution?

The six interconnected modules in Vertusa's solution are: Intake, Admin Review, Clinical Review, Peer-to-Peer Review, Correspondence, and External Entity Review.

How does the solution help in verifying member and provider information?

The solution integrates member and provider databases to simplify the verification process, ensuring that accurate and up-to-date information is used when creating authorization requests.

What is the role of the Admin Review module in the process?

The Admin Review module ensures that the correct clinical documents have been submitted for the authorization request. It provides a document checklist and upload feature, and the case cannot proceed without the necessary documents.

How does the Clinical Review module work in Vertusa's solution?

The Clinical Review module is performed by a registered nurse who reviews all case facts, documents, and clinical guidelines. The nurse has easy access to diagnostic and procedure information, and a 'skip mechanism' is available to expedite the case resolution.

What happens if a case is denied in the system?

If a case is denied, the Medical Review Coordinator (MRC) completes the appropriate documentation, and a denial correspondence is automatically sent to the concerned parties. The MRC may also initiate a peer-to-peer review if the provider disagrees with the decision.

How does the Peer-to-Peer Review module function?

The Peer-to-Peer Review module allows the Medical Review Coordinator to arrange a meeting between the medical director and the care provider to discuss the case. The solution schedules the meeting based on their availability and records the discussions, assisting the medical director in making the final decision.

What is the significance of the Correspondence module in the solution?

The Correspondence module automatically sends approval or denial notifications to all concerned parties. This helps maintain clear and timely communication, ensuring that all stakeholders are informed about the authorization decision.

How does Vertusa's solution handle admission scenarios, particularly pre-planned admissions?

For pre-planned admissions, the solution allows for pre-certification of diagnosis and procedure information before the admission. It covers the entire patient journey from pre-certification to discharge, ensuring that any necessary procedures or stay extensions are properly reviewed and authorized.

How does the solution ensure a smooth discharge process for inpatient cases?

Once the admission case is resolved, the solution automatically routes the inpatient case to the inpatient coordinator. The coordinator verifies the patient's discharge status, ensures that patient instructions are provided, and manages any necessary facility transitions. A discharge summary is also generated, and the case is closed once all details are verified.