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8 Ways to Play the Prior Authorization Game

prior authorization
The prior authorization game is an art, not a science.

There is nothing more frustrating to physicians than knowing a patient needs a certain diagnostic test or medication and having them not be able to get it because their health insurance company won’t cover it. All too often, many services require prior authorization.It wouldn’t be so bad if the insurance companies made the guidelines they use to make these determinations readily apparent to those practicing medicine. However, these guidelines are created by the insurance company.  The guidelines are unavailable to treating clinicians, and often they use decades-old recommendations. We are often left to predict the insurance company’s decision.  The carrier’s main goal is cost containment rather than evidence-based medicine.

Many of us feel that it is like playing an epic game where we try to give our best care to our patients, while the insurance companies deny as many tests as possible to increase their profits. The loser of this game is not the one who was able to get the least amount of services covered or earned the least money. Rather, it is the patient: delayed diagnoses/treatment; denied tests; or forced to use less effective medications based on formularies developed by insurance companies using their own guidelines, and footing increased costs.

How can this prior-authorization game be played for better odds of winning?

– Whoever does the prior authorization needs to have the progress notes in front of them. They will be asked clinical data and it should be at their fingertips.

– Know what needs to be documented in the chart. For example, I had a patient with knee pain who I suspected a torn ligament in the knee. When talking to the rep to get prior-authorization for an MRI, I told her the patient had a positive drawer sign. She never heard of this before and because I didn’t record the results of the Lachman test in the note, she could not approve the MRI. She didn’t know what this test was (I asked) either, but it was a checkmark on her decision tree. I record them all.

– Learn what is needed to get an approval. One example is that with certain insurance companies, every time I order an MRI of the lower back, they want the patient to have had a plain X-ray first. Why? There is no evidence that X-rays are a good test to diagnose back problems. In fact, if I am looking for a herniated disc, a plain X-ray will not show it but rather an MRI is needed. I know this but sometimes the only way to get the patient to get the test is to do it anyway.

– Don’t give up. If a test is denied, appeal it. I find that this is not often successful but sometimes is. Plus, the insurance company should not be given an easy pass for refusing to cover something a patient needs.

– Get the patient involved. Patients should be contacting their insurance company as well. They will be talking to member services and sometimes they find a sympathetic ear who helps them get coverage or reveals the holy grail of coverage determination to them. They are often successful when we are not.

– Remember human resources. If a patient works at a company that has an HR department, have the patient get them involved. Insurance companies do not want to lose any covered lives so if they find a company is unhappy with the services provided, this can be a very effective weapon.

– Ask for the medical director of the insurance company. Most of them were practicing medicine at some point and understand our struggles on the frontlines. If we present our medical reasoning with them, they often are able to authorize a test. Not always.

– Talk to your provider rep at the insurance company. They often know the right person to talk to that may help you get the service covered.

While these tips may help get some prior authorizations approved, they often still do not work. The insurance companies hold a lot of power over these medical decisions. The most important thing is to keep fighting the ones we don’t medically agree with. The day we all quit the battle is the day we lose the game.  Don’t let the big insurance companies win and determine medical care. We must remain diligent in our fight for optimal clinical outcomes in all and each of our patients.

By: Linda Girgis, MD

April 4, 2018

5 Common Reasons Your Claims are Bouncing Back

Billing is a complex and often tedious procedure, especially with ICD-10 codes. However, the reasons for returned and delayed claims often boil down to a few basics. Here are some of the most common billing mistakes practices make, and how to make sure your practice avoids them.

  1. Little Typos, Big Headaches

    Often reimbursements are delayed or denied because of very small, easy-to-make mistakes. “When I was assistant director of billing for a large multi-specialty practice,” says Brennan Cantrell, “the front office would often transpose the numbers or letters in policy number or omit a group number or plan ID. The front desk is extremely busy, and these are easy mistakes to make.” Cantrell, who is now commercial health insurance strategist for the American Academy of Family Physicians, says that the ideal solution is having an employee dedicated to watching for and correcting these errors. For small practices, this may not be a full-time employee, and the time saved by not having to resubmit claims might offset the time spent rooting out mistakes.

  2. Something’s Missing Here

    Sometimes payers delay payment because you didn’t send enough information. Often you can see this coming. “For example, when you file workers’ compensation claims, you will always need to submit documentation with the claim,” says Tammie Olson of Management Resource Group, an Ocean Springs, Miss., a firm offering financial management and support services for the healthcare community. “If you know you need to send the documentation to get a claim paid, do so when you file.”

  3. Please Ask First

    Another incredibly easy—but costly—mistake is not getting prior authorization. “Before you perform procedures, make sure you verify whether or not a prior authorization is required,” says Olson. “If it is, send in the request before scheduling the procedure.” And when you get ready to bill the procedure, “make sure the authorization number is on the claim,” she adds. Prior authorizations can be a pain, but having a routine for them when they are necessary can save time and prevent payment delays.

  4. Let Me See that One More Time

    Claims are increasingly denied because the patient’s coverage has been terminated or the plan or payer has changed.  Most of the time everything is just as it was the last time the patient came in but you should still ask to see the patient’s insurance card at every encounter. “People change insurance plans more often than they used to,” says Cantrell. “It’s a simple thing, but important.” Olson agrees, and adds, “If you do this, you should never have a claim denied for “policy terminated.”

  5. Keep up with the Changes

    Even when policies haven’t changed, what is and is not covered on a given plan sometimes does. You can be left holding the bag if a payer changes its policies about what procedures they cover or what labs they use, and you don’t hear about it. “Most payers send out a policy bulletin announcing these changes,” says Cantrell, “but it’s difficult to find time to keep up with this.” Large practices often have administrators who watch for these changes and pass the word on to each billing office. However, in smaller practices that job may fall to the front desk or billing staff. Make sure whoever does this understands the importance of carefully reviewing these bulletins when they are issued.

 

By: Avery Hurt

Ms. Hurt is a freelance writer based in Birmingham, Ala. Her work has appeared in publications including Newsweek, The New Physician, Muse, Parents, USA Today, and the Washington Post