What is post-acute authorization?
Post-acute authorization, also known as prior authorization for post-acute care, requires that information from both the organization actively managing the patient’s care – as well as the organization that will take over the patient’s care – is sent to the payer or convener, who then either approves or denies the patient’s post-acute stay. Post-acute authorization is conducted prior to a patient’s discharge to a lower level and site of care, such as a skilled nursing facility (SNF) or acute rehabilitation center. The intent of the post-acute authorization process is to ensure that the patient only receives care that is medically justified.
In order to determine whether a patient meets medical criteria for approval, the payer requires information from the stakeholder with the most knowledge regarding a patient’s condition; when the patient is in the acute setting, that stakeholder is the hospital. However, the organization that requires medical approval from the payer is the lower level of care. This organization – a post-acute provider, for example – likely does not have access to the patient’s current condition, and therefore relies on the hospital’s information.
The post-acute authorization process
Post-acute authorization involves a tri-directional workflow, requiring coordination between the payer (or convener), hospital and post-acute provider. A payer’s approval is typically based on three pre-conditions: available benefits, whether the patient medically meets criteria for the requested benefits, or whether the provider is in-network. For example, if a patient has a condition that requires specific treatment and an out-of-network provider can provide that specialized treatment, a payer may make an exception for out-of-network care.
Any status updates in the post-acute authorization process, such as approvals and denials, also need to be communicated to all involved parties. Lower level of care facilities typically have an intake process when accepting new patients, but they must have the resources necessary – for example, bed availability, transportation services, patient medications, or staffing capabilities – to perform this process. If a post-acute provider doesn’t have such resources available, they will not be able to ensure a smooth transition and will therefore not accept the patient until they have those resources in place. Under such circumstances, when post-acute authorization status is not communicated in a quick and efficient manner, the patient will remain in the hospital – resulting in delays in post-acute care and negatively impacting post-acute provider revenue. Also, if a patient receives medical attention in the post-acute setting before the payer agrees on one or more of its three pre-conditions, the patient will be held responsible for medical services rendered. If all three of the payer’s pre-conditions are met, the patient will not have to pay for services rendered.
How can CarePort help?
Hospitals are increasingly taking on the responsibility of post-acute authorization, and are also financially incentivized to streamline their post-acute authorization processes. Not only are hospitals responsible for providing patients a safe transition to their next level of care, but there are also operational and financial benefits to promptly discharging medically-cleared patients; hospitals lose revenue for “avoidable days,” or delays in the discharge process associated with obtaining post-acute authorization.
Many CarePort customers – including hospitals and health systems, as well as at-risk conveners, for example – are responsible for processing post-acute authorization requests. To streamline this workflow, CarePort’s solution for prior authorization for post-acute care – embedded within the discharge planning module that hospitals already use – provides hospitals with the following benefits:
- Automatic notification of post-acute authorization approvals and denials to post-acute providers
- Clinically relevant, clearly presented and well-organized information within the referral
- A centralized location within the hospital’s EMR to document all post-acute authorization activity, further streamlining the patient discharge process
- Improved visibility into a hospital’s post-acute authorization process
- Robust reporting capabilities, empowering acute and post-acute providers to understand staffing needs and negotiate with payers
Acute providers that leverage CarePort’s post-acute authorization tool can seamlessly send a post-acute authorization request to conveners or payers, and ultimately achieve reduced avoidable days associated with obtaining prior authorization for post-acute care.
Ann Maldonado is a Senior Solution Manager with more than 12 years of experience in healthcare IT. Owning product strategies for CarePort’s acute and post-acute users, Ann works closely with clients on post-acute authorization to drive a meaningful solution that improves communications amongst all parties, and provides process efficiencies to reduce unnecessary healthcare costs.
Contact CarePort for more information regarding CarePort’s post-acute authorization offering.