Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

An approach to prior authorization insurance denials

Debraj Mukherjee, MD and Chaim B. Colen, MD
Policy
January 6, 2019
92 Shares
Share
Tweet
Share

Patient access to care is a high priority for all neurosurgeons. Unfortunately, many of our practices are thwarted in these efforts from unwarranted insurance denials. Know, you are not alone. Take this common scenario:

When Ms. Mary Smith (not the patient’s real name) started her new job several years ago, she purchased the premium insurance policy that her company provided. Recently, she developed severe neck and left arm pain. Imaging of her neck with a Cervical MRI demonstrated a large disc herniation at C5-C6 pressing on her left C6 nerve root. Despite attempted non-surgical management including steroids, pain medication, and physical therapy, Mary continued to suffer severe intractable pain and weakness in her left arm. Nearly three months after onset of her symptoms, she presented to a neurosurgeon. Clinical evaluation and review of radiological imaging suggested intractable, severe radiculopathy caused by the C5-C6 disc herniation.

She was scheduled for surgery the following week. However, her “premium” insurance company denied her surgery, claiming that “a physician to physician (peer-to-peer) conference call” was needed. The denied claim cited “lack of sufficient non-surgical management and lack of documentation.” Looking back at the patent medical record all these items had been addressed. Still, the claim was denied and the surgery delayed-leaving the patient to suffer needlessly.

Starting in the 1980s and continuing today, all health care insurers, including Medicare, workers’ compensation programs and private health insurance carriers, have increasingly relied on utilization management (UM) strategies to contain costs. Such strategies have included physician gatekeeper programs, the necessity of second surgical opinions before operative intervention, and prior authorization (PA) for diagnostic tests as well as treatments. Physician practice time associated with UM is estimated at 14.6 hours of dedicated time per practice per week, totaling more than $68,000 per year per practice.

Although dependent upon the particular test or intervention, there is evidence that the rate of first-time insurance denials is increasing over time. A recent retrospective review of 1,054 patients evaluated at a single institution for laparoscopic gastric bypass surgery demonstrated the rate of first-time insurance denial for surgery nearly doubled between 2001 (9.9 percent) and 2005 (19.9 percent). Another recent report demonstrates a wide range of denial rates, from very low for patients with cauda equina syndrome (multiple nerve root compression) to nearly 17 percent for lumbar fusions, highlighting the variable nature of such denials even within the relatively narrow field of lumbar spine surgery. Six-fold variation in denial rates, related to geographic region and payer, have also been documented in the literature. As a result of their often unpredictable nature, physicians are increasingly investing more time and resources toward strategies to combat UM and PA denials.

This UM/PA process is extremely frustrating for patients waiting for care and physicians. A December 2017 survey of 1,000 physicians conducted by the American Medical Association found:

  • 92 percent of the patients requiring pre-approval experience a delay in treatment;
  • 84 percent of physicians reported high or extremely high UM/PA burden, with 86 percent of physicians reporting this burden has increased over the past five years; and
  • 30 percent of physicians reported waiting at least three business days to receive a UM/PA decision from health plans.

Given the above findings, it appears the time may be ripe for physicians to approach the PA process with a more standardized and nuanced approach to obtain more seamless pre-authorization and subsequent patient care.

Advocacy is one part of the solution. The AANS and CNS have joined with the medical community in calling for the standardization of the PA process across diagnostic tests, interventions, payers and providers.  Unfortunately, the diversity and complexity of unifying such processes will likely take much time and investment of resources from all parties.

Until these are fully realized, there are a number of helpful strategies that physicians can employ to help ease the burden on themselves as well as their patients and staff as they approach prior authorizations, including:

  • Adopt standardized forms including a checklist highlighting the necessary tests and interventions that have already been performed on the patient.
  • Back-up the checklist with associated documentation of prior services, including, for instance, documentation of physical therapy sessions or other non-operative interventions that may have been directed by another provider.
  • Create templates for the electronic medical record (EMR) to include progress notes and prior authorization forms.
  • Seek out and become familiar with the specific guidelines and algorithms used by the most frequent payers in your practice. Familiarity with these guidelines can inform the development of internal, standardized forms to expedite processing.
  • Physicians should school their staff on the preparation and submission of documents and ensure proper coding.
  • Your staff can expedite most appeal discussions by scheduling them in advance; thus circumventing the many minutes spent on hold and navigating complex answering systems.
  • During the appeal process, physicians can ask for the credentials of the payer representative who initially denied the request. Often these representatives are either not physicians or not in active practice within the same field of subspecialty. In such cases, the requesting physician may ask to speak with a representative active in practice and within the same subspecialty.
  • Requesting physicians can ask to record their conversation for documentation purposes and/or speak directly to the payer’s medical director.

Such strategies, though not yet rigorously tested, have anecdotally reversed a notable proportion of initial PA rejections in the authors’ practices.  Additionally, the AMA’s Prior Authorization Toolkit provides some outstanding resources and approaches.

At a time when it has become increasingly difficult to obtain first-time pre-authorization for necessary diagnostic tests and interventions, physicians must be increasingly facile in maneuvering UM processes. By increasing our familiarity with national and payer guidelines, standardizing our practice’s documentation, and aggressively rebutting denials, we may continue to advocate for our patients’ best interests and provide outstanding quality and outcomes within our complex and ever-changing health care environment.

Debraj Mukherjee and Chaim B. Colen are neurosurgeons. This article originally appeared on Neurosurgery Blog which is a publication of The American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS).

Image credit: Shutterstock.com

Prev

How to transfer residency programs

January 6, 2019 Kevin 1
…
Next

Net promoter scoring needs to be tweaked for medicine

January 6, 2019 Kevin 0
…

Tagged as: Public Health & Policy, Radiology, Surgery

Post navigation

< Previous Post
How to transfer residency programs
Next Post >
Net promoter scoring needs to be tweaked for medicine

Related Posts

  • Prior authorization reform for health care coverage takes center stage

    Afua Aning, MD
  • A physician’s breakthrough against prior authorization

    Niran S. Al-Agba, MD
  • A patient’s frustrating prior authorization journey

    Leslie G. Bank, PT
  • The answer to your prior authorization problem is simpler than you think

    Dan Richards
  • Here’s why health insurance is different from other insurance

    Joseph Crisp
  • Understanding consent-to-settle in your malpractice insurance policy

    Jennifer Wiggins

More in Policy

  • Why affirmative action is crucial for health equity and social justice in medicine

    Katrina Gipson, MD, MPH
  • The untold story of Hispanic/Latino health: Why subgroup data matters

    Matthew B. Alonso
  • Unmasking the brutal reality of gun violence in America: a call to action for unity and meaningful change

    Osmund Agbo, MD
  • Family physicians unite at the U.S. Capitol, seeking congressional support for Medicare reform and health care transformation

    Tochi Iroku-Malize, MD, MPH, MBA, Sterling N. Ransone, Jr., MD, and Steven P. Furr, MD
  • Breaking down barriers: Illinois bill calls for cultural competency training for physicians to improve health care for LGBTQ+ community

    Michael Pessman
  • Breaking the cycle of racism in health care: a call for anti-racist action

    Tomi Mitchell, MD
  • Most Popular

  • Past Week

    • A patient’s perspective on the diminishing relationship between doctors and patients

      Michele Luckenbaugh | Conditions
    • Unmasking wage disparity in health care: the truth behind the Elmhurst Hospital physician strike

      Kevin Pho, MD | KevinMD
    • Why affirmative action is crucial for health equity and social justice in medicine

      Katrina Gipson, MD, MPH | Policy
    • How electronic health records preserve patients’ legacies in the words of oncologists

      Marc Braunstein, MD, PhD | Physician
    • Unmasking the brutal reality of gun violence in America: a call to action for unity and meaningful change

      Osmund Agbo, MD | Policy
    • Emulating Michael Jordan’s winning mindset: a path to success for health care professionals and entrepreneurs

      Harvey Castro, MD, MBA | Physician
  • Past 6 Months

    • The growing threat to transgender health care: implications for patients, providers, and trainees

      Carson Hartlage | Policy
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
  • Recent Posts

    • Why electronic health records are failing patients: the dark side of copy and paste [PODCAST]

      The Podcast by KevinMD | Podcast
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • The surprising medical mystery of a “good” Hitler: How a rescued kitten revealed a rare movement disorder

      Teresella Gondolo, MD | Conditions
    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

      The Podcast by KevinMD | Podcast
    • Raw humanity on night float: inspiring patient encounters and overcoming challenges

      Johnathan Yao, MD, MPH | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 6 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • 'Medically Relevant to Saving the Life of Your Patient': What We Heard This Week
  • Want to Solve the Nurse Shortage?
  • Why Are Female Doctors Sued Nearly Half as Often as Male Doctors?
  • What Drug Did FDA Just Approve for COVID?
  • PET Scan for Alzheimer's Dx; Predicting Colon Cancer Survival

Meeting Coverage

  • No Access to Routine Healthcare Biggest Barrier to HPV Vaccination
  • Trial Results Spark Talk of Curing More Metastatic Cervical Cancers
  • Cross-Border Collaboration Improves Survival in Pediatric Leukemia Patients
  • Monoclonal Antibody Reduced Need For Transfusions in Low-Risk MDS
  • Less-Invasive Surgery for Pancreatic Cancer Proves Safe, Effective
  • Most Popular

  • Past Week

    • A patient’s perspective on the diminishing relationship between doctors and patients

      Michele Luckenbaugh | Conditions
    • Unmasking wage disparity in health care: the truth behind the Elmhurst Hospital physician strike

      Kevin Pho, MD | KevinMD
    • Why affirmative action is crucial for health equity and social justice in medicine

      Katrina Gipson, MD, MPH | Policy
    • How electronic health records preserve patients’ legacies in the words of oncologists

      Marc Braunstein, MD, PhD | Physician
    • Unmasking the brutal reality of gun violence in America: a call to action for unity and meaningful change

      Osmund Agbo, MD | Policy
    • Emulating Michael Jordan’s winning mindset: a path to success for health care professionals and entrepreneurs

      Harvey Castro, MD, MBA | Physician
  • Past 6 Months

    • The growing threat to transgender health care: implications for patients, providers, and trainees

      Carson Hartlage | Policy
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
  • Recent Posts

    • Why electronic health records are failing patients: the dark side of copy and paste [PODCAST]

      The Podcast by KevinMD | Podcast
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • The surprising medical mystery of a “good” Hitler: How a rescued kitten revealed a rare movement disorder

      Teresella Gondolo, MD | Conditions
    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

      The Podcast by KevinMD | Podcast
    • Raw humanity on night float: inspiring patient encounters and overcoming challenges

      Johnathan Yao, MD, MPH | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

An approach to prior authorization insurance denials
6 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...