Prior Authorization: A Doc Insider Tells How to Prevent Denials

Robert Neaderthal, MD, MBA

Disclosures

August 06, 2019

Robert Neaderthal, MD, MBA

Getting prior authorization (PA) is one of the most frustrating and time-consuming tasks that physicians and their staff have to do.

Physicians may spend between 80 and 100 hours a year on phone calls to get denied prior authorizations approved: waiting on hold, waiting to speak with a medical director, or trying to convince a medical director to overturn their denied CT or MRI. The request may still be denied, possibly requiring an extensive appeals process.

Ten years ago, I retired from my general internal medicine practice in Nashville, Tennessee, and began working as a medical director for a radiology benefits management (RBM) company, which contracted with insurance companies to perform their prior authorization for CTs, MRIs, nuclear cardiac studies, and other tests.

I did thousands of prior authorization case reviews, imaging determinations, and peer-to-peer telephone calls with physicians. I realized that many if not most of these P2Ps were avoidable, if only physicians learned a bit about how RBMs work and used that information to navigate the PA process for the doctor's advantage.

Usually, prior authorization requests are quickly approved by the RBM company. Prior authorization for advanced imaging is now practically universal outside of Medicare, and it shows no signs of going away.

There are four medical services (as distinct from PA for medications) that tend to create the most problems in getting prior authorization. Those services are advanced imaging studies, including CT, MRI, PET, and nuclear cardiac studies. Occasionally, other medical services are subject to PA.

Here are important steps that can help physicians avoid denials and sail through the PA process.

1. Plan for Getting Approval on the First Phone Call

Most requests for imaging studies are approved with a short phone call between the requesting physician's staff and a nurse or clinician at the RBM. In fact, you should usually be able to have your request approved right out of the gate, as long as you understand how the PA process works.

But if some aspect of approval rules hasn't been followed, the RBM nurse can't approve your request, and passes it on to a medical director, a board-certified physician who works for the RBM.

If your request reaches this level, things don't sail along very well, because these requests have problems. Typically, up to about 75% of the requests reviewed by the medical director are denied, often because more information is needed.

All these denied requests can be appealed and subsequently overturned and approved, but the appeal takes extra time, and sometimes a great deal of extra effort. The delays may postpone essential patient care. So it's important to get the request right the first time.

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