Director of Inpatient Rehabilitation Memorial Medical Center Springfield, Illinois, United States
Objectives: To investigate the impact of a novel e-consult with Medicare guidelines on prior authorization approval rates for admission to inpatient rehabilitation for CVA patients.
Design: When submitting for prior authorization, a novel e-consult with Medicare guidelines, also known as a smart phrase, was included and specified to each patient, outlining the ways in which the patient meets Medicare guidelines for admission. The smart phrase was implemented on 12/11/2023 and data has been collected up to 6/30/2024.
Results: First attempt admission rates to inpatient rehabilitation for CVA patients increased after the implementation of the novel smart phrase from 88.8% to 95% (p=0.126). The number of peer to peer reviews conducted for the denials of these patients decreased after implementation of the smart phrase from 21 in the year prior to only 3 in the six months following (p=0.151). Additionally, the number of final denials decreased from 6 to 1 (p=0.523). While these results are not statistically significant, they are clinically significant.
Conclusions: Initial data indicates that including this e-consult note in the form of a smart phrase when requesting prior authorization for inpatient rehabilitation in CVA patients appears to increase first attempt admission rates and decrease the number of peer to peer reviews performed as well as final insurance denials. Further investigation is needed to determine confounding variables and factors leading to increased risk of insurance denial in this population. Continued monitoring, implementation, and evaluation into other diagnoses in inpatient rehabilitation are needed to determine the long term effects of this new form of documentation and statistical significance of its outcomes.
