CIGNA Behavioral Health Practitioner Connection – EFFECTIVE COMMUNICATION SERVES APPROPRIATE AUTHORIZATION

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The Practitioner Conection
Volume XXX, 2nd Quarter

The right help at the right time!

EFFECTIVE COMMUNICATION SERVES APPROPRIATE AUTHORIZATION

CIGNA's mission is to help the people we serve improve their health, well-being and security. Facilitating appropriate coverage authorization is one way we can better serve you and the people receiving your services. When an authorization for coverage is in question, a peer-to-peer discussion between a CIGNA medical director and the facility attending physician (or designee), is the vehicle through which we determine the appropriateness of reimbursement for services. Authorization of services is information-based and effective, therefore complete and timely communication is important. Nearly 76% of all denials for authorization are for requests for ongoing treatments. The most common reason for the denial is inadequate medical necessity information at the time of the peer-to-peer review.

CIGNA conducted a study to help identify ways to increase authorization approvals at the time of a peer-to-peer review, and learned that the role of the individual who shares clinical information at the time of the review has a correlation to the incidence of services being authorized. The findings of our Six Sigma analysis additionally revealed:
• If a CIGNA medical director spoke with a facility physician, the likelihood of authorization was 3 out of 5 times (60%).
• If a CIGNA medical director spoke with the facility utilization review staff, the likelihood of authorization was 1 out of 2 times (50%).
• If there was no telephonic contact of any type between staff at a facility and a CIGNA medical director (review of case notes only), the likelihood of authorization was only 1 out of 5 times (20%).

The study suggests that personal contact, rather than written information, and physician to physician conversation, are most effective when authorization for services is needed.