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
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

ADVERTISEMENT

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

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

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

  • How locum tenens work helps physicians and APPs reclaim control

    Brian Sutter
  • Why Medicaid cuts should alarm every doctor

    Ilan Shapiro, MD
  • Why physician voices matter in the fight against anti-LGBTQ+ laws

    BJ Ferguson
  • The silent toll of ICE raids on U.S. patient care

    Carlin Lockwood
  • What Adam Smith would say about America’s for-profit health care

    M. Bennet Broner, PhD
  • The lab behind the lens: Equity begins with diagnosis

    Michael Misialek, MD
  • Most Popular

  • Past Week

    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why physician voices matter in the fight against anti-LGBTQ+ legislation [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why being a physician mom is harder than anyone admits

      Cynthia Chen-Joea, DO, MPH | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Bureaucracy over care: How the U.S. health care system lost its way

      Kayvan Haddadan, MD | Physician
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
    • Why recovery after illness demands dignity, not suspicion

      Trisza Leann Ray, DO | Physician
  • Recent Posts

    • Why physician voices matter in the fight against anti-LGBTQ+ legislation [PODCAST]

      The Podcast by KevinMD | Podcast
    • The man in seat 11A survived, but why don’t our patients?

      Dr. Vivek Podder | Physician
    • Why gambling addiction is America’s next health crisis

      Safina Adatia, MD | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • How robotics are reshaping the future of vascular procedures

      David Fischel | Conditions
    • Medicalizing burnout misses the real problem

      Jessie Mahoney, MD | 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

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why physician voices matter in the fight against anti-LGBTQ+ legislation [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why being a physician mom is harder than anyone admits

      Cynthia Chen-Joea, DO, MPH | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Bureaucracy over care: How the U.S. health care system lost its way

      Kayvan Haddadan, MD | Physician
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
    • Why recovery after illness demands dignity, not suspicion

      Trisza Leann Ray, DO | Physician
  • Recent Posts

    • Why physician voices matter in the fight against anti-LGBTQ+ legislation [PODCAST]

      The Podcast by KevinMD | Podcast
    • The man in seat 11A survived, but why don’t our patients?

      Dr. Vivek Podder | Physician
    • Why gambling addiction is America’s next health crisis

      Safina Adatia, MD | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • How robotics are reshaping the future of vascular procedures

      David Fischel | Conditions
    • Medicalizing burnout misses the real problem

      Jessie Mahoney, MD | 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...