Ahead of the Patient Access: Maximizing the Revenue Cycle program taking place Tuesday, February 27th, panelist Peggy Fay, MBA, MHA, the Director of Patient Financial Clearance Services and Corporate Business Services at Yale New Haven Health System shares insights into her career journey, as well as the challenges providers face in securing timely prior authorization for medical services. Peggy will be leading a panel discussion during the upcoming meeting on Streamlining Prior Authorization, where she and other industry leaders will discuss the challenges and solutions available.
Tell us about your professional background; how did you get your start in the healthcare industry, and what are some of the roles you’ve enjoyed in your career thus far?
I started my career working for Blue Cross Blue Shield of Florida for a number of years, and then accepted a position with the State of Florida Agency for Health Care Administration; the entity responsible for writing Florida Medicaid policy guidelines, and for administering the program.
Upon returning to my home state of Connecticut, I landed a position with a consulting firm working with providers in New York, Connecticut, and Georgia, to improve revenue cycle effectiveness with a focus on decreasing Providers self-pay populations through Medicaid eligibility while simultaneously increasing federal Disproportionate Share (DSH) reimbursements.
From there, I was recruited by Hartford Healthcare to manage the receivables under self-pay, collections agencies, and financial counseling.
In 2009, I was enticed to move to the Hospital of Saint Raphael’s in New Haven, CT, where I became the Director of Patient Access. In 2012, Saint Raphael’s was acquired by Yale New Haven Health System, forming the basis of today’s health system, which includes six acute care hospitals with over 2,600 beds.
I was tasked with centralizing the functions of financial clearance, bed management, and the operations of the YAccess Transfer Center in 2017, and in January 2022 with the pending acquisition of three additional acute care hospitals, I relinquished my duties in Bed Management and YAccess to focus on the increasing challenges being driven by the ever-changing landscape of Prior Authorizations, Estimates, and Technical Denials.
There are so many challenges associated with securing timely and accurate prior authorization; what would you consider the biggest issue for you and your team; and what are you looking to improve on with regards to prior authorization in 2024?
The question itself embodies the primary challenge. With over 900 insurance companies (NAIC) managing tens of thousands of differing policies, over 6,000 hospitals in 50 states (AHA), and over 950,000 physicians involved in direct patient care (AMA), the rules defining medical necessity changes on a daily basis, as do the regulations required by payers for submitting and receiving prior authorizations.
For more than a decade, the belief that automation can solve the prior authorization puzzle has proven an empty promise, because this type of automation is based on static, reliable, underlying data. This is further complicated by the continuing lack of interoperability with an untold number of third-party vendors offering solutions that must be custom designed to fit every situation.
Something as simple as the automated electronic transmission, a 278N, which has been in existence since 2009, is still not universally used by some of the larger commercial and governmental payers.
My team and I have come to accept the fact that the promise of “end-to-end” solutions offered by consultants and vendors for many years are simply not realistic. We have therefore turned our attention to finding pieces of the authorization puzzle that can be automated. Some of these areas include expanding the use of 278N for Notice of Admissions.
Another promising discovery is with Epic and its Payer Platform product that has been sold by Epic to quite a few Payers. It appears to be able to provide some immediate authorization for a few services, while staying win your own EHR, and uploading clinicals as needed instead of using an another vendor.
The hope with this initiative is that it would enable us to continue to limit the need for staff expansion to handle the ever-expanding volume and complexity of prior authorizations.
We are certainly looking forward to diving deeper into these challenges and solutions during the Prior Authorization panel taking place Tuesday, February 27th during the Patient Access online meeting. Could you share one area you’re looking forward to discussing with the panelists and audience?
Simply put, the challenges of securing timely and accurate prior authorization can only be addressed by eliminating the need for obtaining prior authorization altogether. While this may sound like an impossible dream, the key to making this dream a reality is for the AMA and the American College of Medical Specialties to, once and for all, define medical necessity. Their members are the only ones who can legitimately create and continuously update a database in which clear definitions of the medical necessity for each test, procedure, treatment, and medication prescribed by a credentialed clinician can be made available to providers and payers alike.
I believe that the evolution of the product cited above is an outgrowth of the 2014 PAMA legislation, which led to CMS working with the American College of Radiology to define medical necessity for a range of radiological tests. This data is now being used by an increasing number of providers and payers to effectively eliminate the need for prior authorization for those tests meeting the pre-determined criteria. It is by no means a comprehensive list, but it demonstrates the very practical solution for providing immediate access to needed care at the point a physician places an order.
The perceived impossibility of eliminating the need for payer prior authorization altogether is the biggest obstacle to achieving such a goal, and opening the way for timely access to care while eliminating a huge, expensive administrative burden to both providers and payers.
Thank you, Peggy, for sharing such thoughtful responses! We are truly looking forward to the Patient Access meeting taking place Tuesday, February 27th, and appreciate you joining us in discussing Prior Authorization, and how this challenging process can be streamlined through collaborative efforts between providers, payers, and medical associations.