Prior authorization (PA) has become an everyday activity for providers. The need to obtain approval for a diagnostic test by a third party has become commonplace not only for costly surgical procedures, but also for medicines and imaging. Initially, prior authorization applied only to expensive imaging such as CT, PET and MRI but now PA is even required by some payers for lower cost procedures such as ultrasound and Doppler.
As noted elsewhere on this website this blog will teach the tools that you need to avoid p2p phone calls, also called the Keys to the Castle. Postings will describe each of the 4 Keys, beginning with a discussion of how radiology benefit management (RBM) companies operate. By understanding how RBMs perform their intake and approval process, you will be better prepared to successfully navigate the entire system. This will allow you to obtain authorization “right out of the gate.” When you are able to obtain the authorization number easily and consistently, you will be amazed at the extra time you have saved by not having to appeal denied imaging studies. So the RBM intake processes made simple constitute the first key to the castle.
Although I worked for 7 years with one Radiology Benefits Management company, I have discovered that all the major RBMs perform their intake process in the very same way. All allow authorization to be requested via a telephone call or through a web portal. But the general principles of intake do not differ between the different RBMs.
The prior authorization process begins in your office when you select one of your employees to contact the RBM to obtain an authorization. Without the authorization number, insurers will not pay for the imaging study and some imaging facilities will not even schedule the test without that number. This employee may be a nurse or a receptionist, a clerical person or a medical assistant. In large practices with many imaging requests, a dedicated employee may be appointed just to perform prior authorization. For lack of a formal title, I refer to that person as the “Doctor’s PAL,” (which stands for Prior Authorization Liaison.) Your PAL may be medically trained or may have only limited clinical knowledge. Nevertheless, this person plays an essential role in your effort to avoid p2p calls. When the PAL is successful and acquires the PA number “right out of the gate,” you will NOT have to wait on hold to speak with a medical director late in the afternoon!
When you decide your patient needs a CT or an MRI or a nuclear cardiac study, the PAL is the person to whom you turn to obtain that authorization number. The PAL will then contact the RBM, either by phone or through a secure web portal. In this example, we will propose your PAL contacts the RBM by the telephone
The beginning of the call between your PAL and the RBM employee is in part for identification: The RBM needs to identify the patient, the ordering provider, the name of the insurance company, and the imaging facility. Once the RBM ensures the doctor and imaging facility participates with the patient's insurance company, the PAL is asked for the name of the requested imaging study and the reason for the request.
Your PAL is then asked to provide clinical information. Based on the imaging test desired and the reason for requesting the test, the PAL is asked 8-10 clinical questions. There is nothing mysterious about these questions and they are not secrets. They are the “who, what, when, where, and why” questions you were taught to ask patients way back in medical school. As the PAL provides clinical information on the case, the nurse busily enters the responses to the questions into the patient’s database. At the same time, the nurse is referring to a set of evidence-based guidelines, to see if the clinical information provided by the PAL meets the criteria in the guidelines.
If the clinical information meets the guidelines, the RBM will approve the request, generate an authorization number, and provide that number to the PAL. But if the criteria are not met, the nurse cannot deny the request. For some RBMs, the nurse must send the case on to a medical director who is the only one who can deny the study. With other RBMs, a peer-to-peer with a medical director is automatic and immediate if the nurse cannot approve the request. Since only a medical director can deny an imaging request, it makes sense to make sure your PAL has the information available for the nurse for an immediate approval.
The 1st Key to the Castle: The nurse can approve any imaging study you request, BUT the nurse does not have the authority to DENY requests. Therefore, try to encourage your PAL to provide the clinical information that will result in an immediate approval.
In the event of a denied requested imaging study, providers have the option to appeal. Appeals require the submission of additional clinical information and the denial is reconsidered. The appeal that is the most time-consuming and frustrating for providers is called the peer-to-peer. For this appeal, physicians, nurse practitioners, or physician assistants must speak directly with an RBM medical director to discuss the case and provide additional clinical information. Often the new information results in the medical director overturning the denial and issuing an authorization number. However, this type of appeal may take between 10-20 minutes to complete. In a busy practice with frequent imaging denials, the time wasted performing p2p calls may add up to several weeks each year. For this reason, the first key to the castle is to understand how this intake and review process works, and to make sure your PAL obtains that authorization number “right out of the gate.”
Take-home lesson: The first key to the castle is “The nurse can approve any imaging request, but the nurse cannot deny anything. Therefore get your authorization during that initial call and do not wait for a medical director or a peer-to-peer call.
In the next blog posting, we will begin to discuss exactly HOW you can get authorization “right out of the gate.”