Navigating the Business of Medicine: Submitting Successful Prior Authorizations
This blog post discusses the ins and outs of submitting prior authorizations, a process that has become increasingly common in healthcare. Prior authorization is a requirement from an insurance company for certain procedures or medications before they will cover the cost.
The blog post outlines the key steps for submitting successful prior authorizations and emphasizes the importance of having a well-organized system in place to streamline the process. Here are the key takeaways:
Gather all the necessary information upfront. This includes the patient's demographic information, the CPT code for the service being requested, relevant diagnosis codes, and a clear explanation of why the test or treatment is necessary. Additionally, you may need to include any relevant chart notes, such as X-ray results, to support your request.
Use a template to ensure you don't miss anything. Having a template handy will help you ensure that you gather all the required information each time you need to submit a prior authorization.
Understand the importance of step therapy. For medications, this means documenting that the patient has tried and failed other, less expensive medications before requesting approval for a more expensive one.
Be prepared to justify the need for the service. Insurance companies are increasingly scrutinizing prior authorization requests, so be prepared to clearly explain why the requested test or treatment is necessary and why other options have not been successful.
Track your requests and follow up as needed. Don't assume that your request will be automatically approved. It is important to track the status of your requests and follow up with the insurance company if you don't hear back in a timely manner.
Surgical authorizations fail for a different reason than medication authorizations: the request is usually complete, but the clinical criteria are not yet met. Orthopedic practices see this constantly, where a payer requires a documented course of physical therapy, a specific duration of symptoms, or imaging findings matching the proposed procedure before approving a joint replacement or arthroscopy. Submitting before those boxes are checked produces a denial that then has to be appealed, delaying surgery by weeks. Reading the payer’s medical policy before the request goes out, rather than after it comes back, is one of the habits that moves approval rates most, and it is standard practice for an orthopedic billing service.
By following these tips, you can increase your chances of getting prior authorizations approved quickly and efficiently. This can save time and money for both your practice and your patients.
The article also highlights the fact that submitting prior authorizations can be a time-consuming and complex task. It acknowledges that this can be a burden on small practices and encourages readers to share their experiences and tips for streamlining the process.
