Date of Doctor of Nursing Practice Project Completion
2025
Faculty Advisor
Dr. Daisy Mullassery
Abstract
PURPOSE The purpose of this project was to improve the prior authorization process for payer, provider, and patients by reducing the number of medical necessity denials, peer-to-peer calls, appeals, and increasing payer and provider satisfaction.
BACKGROUND A literature review indicated opportunities for improvement in prior authorization processes. Medical necessity denials are issued by payer if clinical documentation is not available for review. Implementation setting was a large academic medical center. Studied populations included patients who are members of a large Medicaid HMO health plan, payer utilization review registered nurses (RN), and hospital utilization review staff. METHODOLOGY Payer RNs began utilizing the facility electronic health record (EHR) after receiving access and training. Pre and post-implementation data was analyzed. Payer RN satisfaction survey data was collected. Lean Six Sigma Model was used as it aligns with payer’s organizational strategies.
RESULTS Pre-implementation findings: denials 6.2%, peer-to-peers 13.3%, appeals 6.67%. Post-implementation findings: denials 3.66% at 45 days and 2.4% at 90 days, peer-to-peers 14.3% at 45 days and 50% at 90 days, appeals 0% at 45 days and 0% at 90 days. 100% of payer RNs who participated in survey felt this process was beneficial to their roles. 100% positive feedback was received from the medical center.
IMPLICATIONS Direct access to the facility EHR resulted in fewer medical necessity denials and appeals, and improved payer and provider satisfaction. There was limited data directly related to accessing the facility EHR to conduct medical necessity reviews for inpatient hospital stays, therefore additional research is indicated.
Keywords
electronic health record, payer utilization review, utilization management, medical necessity denial
Recommended Citation
Denton, Betsey, "Accessing Facility Electronic Health Record for Payer Utilization Review Review" (2025). Doctor of Nursing Practice Final Project Abstract. 79.
https://digitalcommons.library.tmc.edu/dnp_abstract/79