Prior Authorization: A Doc Insider Tells How to Prevent Denials

Robert Neaderthal, MD, MBA


August 06, 2019

5. Pay Attention to the Nuances

Interpreting the guidelines correctly has a lot to do with appreciating the nuances. Here are two examples:

  • Before an MRI of the lumbar spine can be approved, the patient is often required to undergo 6 weeks of conservative care. Many physicians are unsure when the clock begins ticking for the 6 weeks, or exactly what care constitutes conservative care, but all of this is spelled out clearly in the guidelines.

  • To get approval for a CT of the abdomen, instead of an abdominal ultrasound, at least one of the RBM's "red flag" symptoms must be present. So it helps to know what those red flags are. They are found in the abdominal pain guideline.

6. Expect Guidelines to Support Quality

When RBMs apply the guidelines, effectiveness and patient safety come before cost savings. In many cases, all three measures apply.

In fact, the RBM in some cases will direct doctors to switch to a more expensive modality that is more effective or less risky for the patient.

For example, many physicians are unsure when to order a CT with contrast, without contrast, or with both. So they request both, which doubles the radiation and is often unnecessary. The guidelines call for keeping radiation exposure to a minimum.

7. Know How to Appeal a Denial

You'll always have a chance to appeal a denial. Once the needed information is provided, an approval often goes through. There are basically two kinds of appeal:

  • In a simple appeal, your staff member provides the missing information and asks for a review of the denial. Sending the RBM verification of a prior chest x-ray, for example, can immediately result in approval.

  • Some appeals require a peer-to-peer phone call. This is necessary when the requesting physician wants to provide additional information or explain extenuating circumstances that would warrant approval. Peer-to-peer calls on the appeal level often result in approval.


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