In my role as a speech therapy clinical reviewer for eviCore, I assess documentation for services deemed medically necessary. As a certified speech language pathologist, I understand and appreciate the common challenges experienced by my peers working on the front lines, and I want to help you navigate the process so you can help your patients.
The documentation requirements for prior authorization approval can sometimes seem daunting, particularly when one therapist is treating patients from a variety of insurance carriers who require prior authorization from various sources. However, the frustration of unnecessary denials can easily be avoided – one of the most common reasons for them is missing or inadequate documentation.
In an all-too-common conversation I have with clinicians when services are denied, the information was readily available, but the required documentation unfortunately wasn't submitted, leading to a denial of services, a peer-to-peer phone call and a delay in service for their patients.
Although specific expectations will differ across insurance carriers, there are some general rules of the road for documentation requirements that are typically needed from a clinical review standpoint.
Current Information: Documentation is time-sensitive. It is important to be aware of the timeline requirements for each insurance plan and send information in a timely manner.
Evaluation Findings: Another important step is to verify that the most recent evaluation clinical findings have been submitted for review. Even if the patient has been receiving care and a progress report is necessary, it is imperative to verify that the current evaluation findings are on file with the clinical reviewer.
Objective Measures: A clinical reviewer must be able to compare the patient's abilities to appropriate norms for the age and condition addressed. This includes all applicable standardized evaluations (CELF-5 for pediatric language or BDAE-3 for adult aphasia) and procedures (s/z ratio and maximum phonation time for voice). These objective measures must correlate with the areas addressed in the plan of care.
The American Speech Language Hearing Association (ASHA) has developed some helpful guidelines for assessments. This information can be found in ASHA's preferred practice patterns.
Subjective Findings: Patient-specific information that impacts quality of life should be considered in a medical necessity review. For example, a cognitive assessment may show reasoning skills to be low average. However, subjective information may indicate the patient is an engineer and previous reasoning abilities were in the 90th percentile. The patient's goal is to return to work. This type of subjective information can make a significant difference in clinical review.
Long- and Short-Term Goals: The acronym SMART has become more prominent recently in relation to goal setting. Although there is some variation in the terminology associated with this acronym, the representation of the concepts is the same.
Specific: The goal must clearly identify the objective.
Measurable: The goal must include an objective way to evaluate achievement or lack thereof.
Achievable: The goal needs to be scaffolded to be achievable for the patient.
Relevant: The goal needs be functional for the patient and his/her caregivers.
Time-related: The goal should include a timeline associated with the goal's achievement.
Including each of these elements in your goals will be essential to providing evidence of patient progress and the benefits of the skilled services you provide. In addition to the SMART elements, both baseline and current measures of each goal are needed. Including current and beginning baseline measures for progress is often overlooked when submitting documentation.
Objective progress towards short-term goals:
Baseline or beginning measures and objective progress measures are needed for long- and short-term goals. Progress reporting must include the baseline or beginning measures of your goal, and the current level in objective and measurable terms. To simply write "progressing," "continue," "not met" [AM6] or a similar generic term in response to a goal is not sufficient information for a clinical review.
Example of Insufficient Progress Reporting:
Patient will categorize 20 functional household items into four categories by June, 2018. - Progressing
Example of Sufficient Progress Reporting:
Patient will categorize 20 functional household items into four categories by June, 2018.
Baseline - 25%; Current Level - 75% or
Baseline - 5/20 items correct; Current Level-15/20 items correct
A last note regarding progress measures is to include a clear rationale for patients who are not progressing as expected towards goals. A clinical reviewer will consider circumstances that have resulted in less-than-expected progress, but the reasoning must be specifically documented.
Hopefully, this guide will assist in navigating documentation requirements and expectations to avoid common pitfalls and delays. By implementing these strategies, the positive impact of your professional services will be accurately portrayed, paving the way to swifter approvals, and allowing you to help your patient receive the care they need.
Sarah Hardison MA, CCC-SLP, Speech Language Pathologist, Clinical Peer Reviewer
eviCore Healthcare, 80 Spring Lane, Plainville, CT 06062