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Q: We are thinking about placing outpatient precertification functions in patient access instead of in the case management department. We think it will help us get the precert in a more timely manner. What are the biggest pros and cons?

Patient Financial Services Weekly Advisor, April 9, 2004

A: The pre-cert is the crossroads of financial and clinical information. If a precert is not properly obtained, the financial risk to the hospital is significant. This means that performing the precert in an area that is financially focused is imperative. Both patient access and case management can be excellent locations.

The most important factors are tied to how those departments are structured. Therefore, use the following criteria to determine the best place to put this function:

1. Does the department report to the financial side of the organization (i.e., to the CFO)?

2. Can the department focus on this item or is it likely to be caught off guard when volume or acuity changes?

3. Will the referral patterns of physicians be changed if the precert function is changed?

4. Will the department be held accountable for the timely completion of these items?

5. Will there be reporting and feedback available to the employees who do this work so they know whether they are doing a good job?

6. Do the employees have the education and skills to complete the tasks?

Based on my experience, the patient-access areas have been positioned appropriately to best protect the hospital from a financial perspective. However, patient access must intentionally compensate for their lack of clinical background and skill.

This question was answered by PFS Advisor editorial board member Daniel Wolcott, MBA, director of patient financial services at Florida Hospital Memorial Division.

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