With the recent revisions and improvements that CMS just came out with for Prior Authorizations (CLICK HERE), it's important for physicians to know as much as possible to streamline the process, and maximize the approval rates. Below is an article from Medical Economics, that dictates 8 significant steps to do this.
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 (PA). 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 (with the main goal being cost containment rather than evidence-based medicine), unavailable to treating clinicians, and often they use decades-old recommendations.
Physicians offices are often left to predict the insurance company’s decision. Many feel it is like playing an epic game where they try to give their best care to patients, while 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, forced to use less effective medications based on formularies developed by insurance companies using their own guidelines, and footing increased costs.
Here are 8 ways to make prior authorizations easier:
Whoever does the PA needs to have the progress notes in front of them
They will be asked for 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 had 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.
If something is abnormal, stop and document
Jot a quick note to yourself or type in the abnormal exam into the computer. It only takes a moment and improves the likelihood that you will accurately capture the exam.
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. 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 and keep appealing 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
They 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 understood our struggles on the frontlines. If we present our medical reasoning with them, they often are able to authorize a test.
View full article from Medical Economics, November 2021 HERE: 8 ways to make prior authorizations easier (medicaleconomics.com)
View CMS overview of new Prior Authorization Processes HERE: https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process