The When and How of Prior Authorization

The When and How of Prior Authorization

Prior authorization for healthcare services is required for certain services. If authorization is not obtained prior to performing the service, the insurer may not reimburse for the procedure. Most services requiring prior authorizations are surgical procedures or high-cost ancillary services or may be determined as not necessary in some circumstances.

The requirement for prior authorizations can lead to delays in needed healthcare, affecting both patient outcomes and patient satisfaction. According to an AMA survey, respondents reported an “average of 14.6 hours (approximately two business days) spent each week by the physician/staff” to complete this prior authorizations workload. And, 78 percent of respondents reported that prior authorizations can “at least sometimes lead to treatment abandonment.”

The AMA has urged payers to reform their prior authorization requirements, but for now, the more efficient your system for handling these authorizations, the better off your patients (and your bottom line).

The method to obtain prior authorizations can differ from payer to payer, but usually is performed by either a phone call, the submission of an authorization form, or an online request via the payer’s website. Most often, payer portals are the preferred method of submitting a prior authorizations. The portals may allow you to register for access, or you may have to gain access through your facility’s administrator.

To determine whether a service requires an authorization, you must be aware of each payer’s policies, which can usually be found on the payer Website and the payer/provider contract. Because of the need to describe medical necessity, this is most commonly performed by a medical assistant or other staff who can effectively communicate to the payer with an understanding of medical procedures.

The person seeking the authorization should have the patient’s progress notes in front of the, so that they are prepared to share any necessary clinical data. You’ll want to be sure that you’ve performed any necessary tests or prerequisite treatments, and that these are documented, prior to seeking authorization for further services. Be persistent in your requests, ask to speak with the medical directory, and—if necessary—get the patient involved. Survey other providers, to learn how they handle prior authorizations. Finally, be sure to track your requests, following up to prevent delays due to lost or incomplete information submitted to the payer.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

One Response to “The When and How of Prior Authorization”

  1. maxine dorsey says:

    Great article! I work for an insurance company in this department and often we find that providers will call and not have the key information that is needed for the determination. Unless the service is emergent there are guidelines that we follow in order to give each department that has to process the case gets the time needed for the approval and when denials are rendered, notices and options need to be addressed.
    The team that I work with handle thousands of calls a week and as good as we may be many times we encounter providers not willing to get the request/ referrals needed for the patient and will send the patient unprepared to call us and become frustrated when they aren’t able to get the authorizations needed. As a result, when we see them unwilling to get the services they need because the process is too daunting.
    Your so on point about following up on cases that are started and pend! Many providers will set up the case and will not follow up or send in the information needed to make the proper decision and this causes denials due to lack of information (LOI). This too is a huge problem due to the fact that once the time line for these decisions have lapse, reconsiderations – appeals – or peer to peer (P2P) are the next steps which adds extra delays.
    Lastly, it is extremely important for the provider to have the correct member insurance information! Because the patient is not likely to know or understand when they’re policies are changing and what that means, a lot of times things that didn’t require authorizations under the precious policy will require under the new one. It is a continuous process for us in the authorization department and we constantly educate the provide on how to make the process much smoother.

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