DECREASING COMPLAINTS AND APPEALS REGARDING REFERRALS

Addressing Opportunities for Improvement

When this plan implemented a new computerized system to capture data about appeals and complaints, it improved its ability to spot trends easily. It discovered that complaints and appeals about the referral process accounted for disproportionate shares of the totals.

Even though primary care providers had received ongoing education regarding the use of participating providers and how to obtain the necessary preauthorization for their patients' services, the number of referrals not following the precertification process was on the rise.

Concerned with member and provider satisfaction, the plan was prompted to review its data on complaints and appeals related to the referral process, and to recommend a course of action.

The targeted population was the entire plan membership. Specifically affected by the activity were all members who needed referrals.

The plan used a computerized data system that produced monthly totals by complaint and appeal category and subcategory. It also produced quarterly and annual aggregations.

RELATIVE GOALS Goals serve a number of purposes in a quality improvement activity. The main purpose is to clearly communicate to a large group of people what a group is working to accomplish. Goals let everyone know if their efforts have been rewarded, or if there is more work to be done. Goals that utilize a specific number generally communicate these points better than those calling for a certain percentage improvement. Goals calling for relative percentages can be even more volatile. An upsurge in complaints or appeals from other causes could reduce the percentage from referrals, even with no improvement in the referral system. Similarly, improvements in service across the board might cause a greatly improved referral system to exceed its percentage of a reduced number of overall complaints or appeals.

The plan chose six quantifiable measures:

• Number of member complaints about referral authorizations
• Referral authorization complaints as a percentage of total complaints
• Rate of referral authorization complaints per 1,000 members per month
• Number of appeals about referral authorizations
• Referral authorization appeals as a percentage of total appeals
• Rate of referral authorization appeals per 1,000 members per month

Baseline measurement came from system information from the July 1996 to June 1996 time frame. The plan established performance goals for two of its six measures:

• Three percent or less of all complaints should be related to referral authorizations
• Twenty-five percent or less of all appeals should be related to referral authorizations

Representatives from utilization management, member services, and provider relations collaborated on this activity. A subcommittee composed of UM managers, the medical director, and representatives from provider relations, case management and IS, carried out most of the barrier analysis. They largely depended on brainstorming, but the interdisciplinary nature of the group contributed greatly to joint problem solving.

The major identified barrier was felt to be the requirement that all specialty referrals and diagnostic procedures have authorizations. Many physicians simply didn't comply with this requirement, resulting in many denials and retrospective authorization requests.

The plan determined that it could not achieve its goals if it placed all its emphasis on educating practitioners on how to obtain referral authorizations. It decided to expend more energy on changing its referral processes, over which it had more control.

It felt it needed to simplify its referral process, and train the claims staff and the practitioners on the new process.

It eliminated the need for a member to get an authorization number prior to seeing a participating specialist. It reduced the number of diagnostic procedures that needed an authorization number.

IMPLEMENTING CHANGE Plan staff worked with personnel at the claims service center, which was located out-of-state, to ensure the accuracy of claims rules prior to the implementation of the new system. Nevertheless, changes to the claims systems that were to have been implemented in October 1996 had still not been fully implemented in May 1997. While undoubtedly this affected remeasurement results, it was more important that the plan was able to follow up on implementation by the claims department, and oversee the necessary changes.

The plan mailed out a notice to all practitioners explaining the new referral process.

The first remeasurement was based on data from July 1996 to June 1997. Although the percentage of complaints due to referral authorizations actually worsened, this change from baseline was not statistically significant. There was a significant improvement in the percentage of appeals due to referral authorizations, however.

The plan identified several new and important barriers, viewed them as opportunities for improvement, and designed strong interventions aimed at improvement.

POINT OF SERVICE INFORMATION SYSTEMS This plan tried two technology solutions: interactive voice using the telephone system, and swipe card technology using a special box and electronic transmission. Office staff swiped the member's ID card, and punched in the provider ID number. These boxes were first installed at several large groups, at the plan's expense. Later, all practitioners were able to purchase the special boxes. This swipe card technology proved to be much faster than the interactive voice system, and came into widespread use.

Most important of these new barriers was the plan's administration of specific subnetworks within its overall provider network. Specialist referrals were restricted to specialists within a specific subnetwork. Computerized decision rules prevented directing members outside their subnetwork.

The plan realized that it needed to expand the use of its entire network of specialists. It removed the financial and contractual barriers that had limited referrals to a subnetwork, and allowed referrals to all participating specialists.

Even with full implementation of the previous changes to the referral process, practitioners still needed to call the plan for precertification of a variety of procedures. The plan further reduced the number of these procedures, and introduced two technology solutions for practitioners seeking authorization numbers. Both an interactive voice response system and a swipe card system delivered automatic authorizations for services.

Plan staff worked at informing providers of the new policies, rules and solutions. Newsletter articles were combined with on-site visits to the largest groups. Plan staff also visited the out-of-state claims service center to train staff on the appropriate implementation of the new changes to the referral system.

The second remeasurement used data from July 1997 to June 1998.

These data represented a statistically significant decrease from both baseline and the previous year for the contribution of the referral process to both complaints and appeals.

The plan identified a continued need for education at both its claims service center and its practitioners' offices. A high number of calls continued to be misdirected to the UM department by the claims service center. Many of these calls were from providers about basic subjects that should not have required a call, such as what services required prior authorization. The plan initiated training for the largest medical groups.

The out-of-state claims service center took over the member services functions as well. Rapid hiring of new staff unfamiliar with the plan requirements represented a potential barrier to a smoothly functioning referral system. The plan addressed this with intense education efforts, and enhanced system support from the corporate parent organization. It introduced an enhanced computer system to assist member service representatives. Each representative had access to a number of computer screens about city-specific details on members, practitioners, and local decision rules.

The swipe card authorization system was expanded to a PC application. The system automatically checked all requests to see if prior authorization was necessary. If it was, the request was automatically sent to the plan's UM department.

The third remeasurement used data from July 1998 to June 1999:

These data showed sustained improvement over baseline performance; the plan had met its two performance goals.

The plan states that it believes its current complaints due to referrals are at less than 1 percent of the total, while appeals about referrals are "virtually nonexistent."

The plan believes that it has positively affected member satisfaction with this activity. It points to this activity and to its very high CAHPS scores as continuing evidence of the organization's concern and success in improving member and provider satisfaction.