AANS Neurosurgeon : Practice Management

Volume 24, Number 2, 2015

Navigating Prior Authorizations

David S. Robinson, BS, RMA

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As health-care providers, we strive to provide our patients with the best medicine we possibly can. There are certain barriers that impede the process of quality health care. Having to obtain prior authorizations from insurance companies is one of those barriers. While this may seem like a simple hoop to jump through, it can actually be one of the most daunting tasks that a physician’s office undertakes. Gathering information to meet certain criteria that ensures the patient’s authorization will be completed with an approval is often nerve-racking and overwhelming.

Services that usually require a prior authorization include:

  • Imaging: MRI, CT scan, Pet scan
  • Surgery: Any type of specialized surgery (i.e. neurosurgery, Gamma Knife, etc.)
  • Prescriptions: Non-formulary is the most difficult and always needs a prior authorization.

Authorizations can be obtained three different ways. Each vary by insurance or pharmaceutical company.

  • Telephone: Expect to wade through menus and automated systems and then wait for at least 30 minutes for anyone to answer.
  • Online: This process seems to be catching on in the insurance world faster than the pharmaceutical world. As long as the system is running and is up to date, it should be a little smoother process than the phone.
  • Paper forms: This is the longest authorization process. Everything must be printed and sent into the company, which is followed by a long wait for a response.

Acquiring Prior Authorization
Provider documentation plays a key role in the prior authorization process. Proper ICD-9 and CPT codes must be provided for the authorization to be approved. Most authorizations can be obtained by giving clinical information, such as current and previous symptoms, current medications, previous conservative treatments and test results. However, there are some insurance companies that require medical records to be faxed before authorization is provided. Also, if a procedure or prescription is denied, medical records must be provided. The prior authorization, medical review or appeals department will request that your office send any documentation, previous test results and treatment notes for their review to determine if it meets medical guideline approval.

Below are some tips to streamline the authorization process:

  • Review the insurance company’s medical benefits guide, which is often available online. The benefits will tell you whether or not the procedure or device is a covered benefit. Knowing what the benefits are help the staff make a decision on how to obtain approval for the patient or if they need the neurosurgeon to make another recommendation.
  • After pre-approving procedures with your top 10 insurance companies, the staff should have a good idea of what is expected for conservative therapy. After the patient has undergone these required therapies, the staff has a much better chance of obtaining authorization. See an example of how to make a chart of each of your top insurance companies’ requirements for various procedures.
  • Identify the medical director of the plan and call the physician directly to explain the situation and ask for help in the authorization process. It is possible to obtain the ability to bypass some of the authorization requirements by meeting with the medical director.

Most insurance companies will provide a 72-hour processing time for authorizations. However, there are some insurance companies that give a generic disclaimer, such as 10 to 14 days for processing a prior authorization.

What to Do When the Request Is Denied
When a procedure or a prescription is denied, most insurance companies will require a peer-to-peer review from the medical provider. If they deny it after the peer-to-peer review, an appeal request can be initiated or another form of treatment can be recommended by the medical provider.

The peer-to-peer process does not always appear to be valid. Some insurance companies are using insurance representatives as the peer reviewer. Others use physicians who are not in the same specialty. When did it became common practice for an insurance company to dictate or decide what is within the best interest of the patient? The reason physicians complete medical school and board certification is to give the patient the best possible treatment.

In conclusion, there are some things that would help expedite the process of a prior authorization. The most important thing is to document all conservative treatments. Also, be open to a peer-to-peer review even though it takes time out of your busy schedule. It is the easiest way for the process to be completed. With teamwork and the proper resources, the process can be done efficiently and effectively for the good of the patient.

David S. Robinson, BS, RMA, is the practice administrator for Northwest Neurospecialists PLLC, Tucson, Ariz. The author reported no conflicts for disclosure.

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