An approach to prior authorization insurance denials

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

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