Prior Authorization: A Doc Insider Tells How to Prevent Denials

Robert Neaderthal, MD, MBA


August 06, 2019

2. Have All Necessary Clinical Information Ready

The key to getting your request right the first time is your PA liaison (PAL): the staff member who contacts the RBM for the initial request. To be successful, your staff member needs to understand what clinical information will be needed, and then have full access to it.

For example, many denials for a CT of the chest involve lack of a report on a chest x-ray, which is needed before the CT can be approved. In many of the denials, the chest x-ray was actually taken, but it was not in the medical records when the PAL called. So the claim had to be denied.

The lesson: Doctors need to make sure that information like a pertinent laboratory test or a completed chest x-ray is handed over to their PALs. Without these, the request is typically denied.

3. Know the Guidelines

Each RBM publishes a set of guidelines for ordering the services it covers. The guidelines are a roadmap for how you and your staff get approval for your requests from the get-go.

The questions the RBM nurse asks are based on these guidelines. So if you and your PAL have carefully read the guidelines and discussed the clinical details of the case, your PAL will be able to answer all the questions and gain approval immediately. When this happens, the requesting doctor doesn't have to get involved.

Reading a prior authorization guideline carefully is often not that difficult, because the RBM has taken very lengthy guidelines from specialty societies and distilled them to text that usually runs no more than a page.

Because the guidelines all come from the same sources (mainly the specialty societies), they don't vary that much from RBM to RBM. Therefore, following one RBM's guidelines is sufficient.

What's important is that the guidelines are read. If you find your office is experiencing a large number of denials, or many denials regarding one particular procedure, it's wise to re-read the guidelines and discuss them with the staff member who creates the request for the procedure.

4. Keep the Guidelines Handy

RBMs don't publish the questions they ask in the call with your PAL, but they do publish the guidelines on their websites. Because the RBM nurse's questions are completely based on the guidelines, a close reading of the guidelines shows you what the questions will be.

It's a good idea for you and your PAL to download the guidelines and keep them on your computer desktops for easy reference. The text is searchable, so it's easy to find a particular aspect you are looking for by entering a keyword.

To find the guidelines, go to the websites of the biggest RBMs, such as EviCore, American Imaging Management, and National Imaging Associates-Magellan Health Services. Then copy and paste the guidelines on your computer.


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