Background: The insurance authorization process for Inpatient Rehab Facility (IRF) and Skilled Nursing Facility placement is lengthy. It takes several days for insurance companies to make decisions regarding patient disposition. This creates increased length of stay (LOS) for otherwise medically stable patients. Several factors contribute to delays and include the lack of weekend authorization staff to process referral paperwork. Delays in authorization and disposition cause medically stable patients to remain unnecessarily in acute-care hospital beds, and increase costs when lower levels of care can be utilized.The purpose of this study is to examine LOS increase caused by insurance authorization delays on medically stable patients otherwise ready for discharge. This study seeks to investigate if authorization time mandates would be helpful to facilitate patient disposition.

Methods: Data was collected from 6/30/14 to 6/30/19 in patients denied insurance authorization to IRFs. The sample includes 198 IRF-denied candidates that had to find alternative dispositions. 22 were excluded because medical reasons caused delays. 7 patients were excluded because alternative dispositions were chosen. 11 were excluded because identifying information was unavailable. Total sample: 158 patients. Information obtained through E-rehab data was verified through individual patient chart review. The LOS extension was determined by the date patients deemed medically stable for discharge had referrals submitted for IRFs minus the date insurance-authorized dispositions were determined.

Results: Of 158 patients denied IRF authorization, the average LOS increase beyond when patients were medically stable for discharge was 5 days. The majority of patients with IRF denials were Medicare Advantage patients (81%), with the highest average increase in LOS attributed to Aetna MA (7 days). Humana MA represented 30% of the MCA patients (5 days of increased LOS). The shortest LOS extension occurred in Cigna private insured patients (3 days).

Conclusions: The authorization process for insurers/payers to determine dispositions for medically stable patients creates unnecessary delays in discharge. The average LOS increase per patient awaiting then receiving an alternate disposition after IRF denial is 5 days beyond when they are medically stable for discharge. The majority of LOS extension is due to the authorization process, denial, and seeking an alternative disposition for the patient. Some of LOS extension occurred because weekend authorization staff was lacking by insurance companies. Information is needed to determine if denial appeal processes (peer-to-peer) affects LOS. Limitations include inability to track whether information wasn’t received by payers/insurers and if this contributed to delays.Increased LOS in medically stable patients contributes to patient dissatisfaction, and further risk of hospital-associated illnesses. A mandate or policy could be incorporated to reduce the time which insurers make authorization decisions.

IMAGE 1: Medicare Advantage

IMAGE 2: Percentage of Denials by Payer