While serving as a medical director for a large radiology benefits management (RBM) company, I reviewed thousands of imaging requests and performed thousands of peer-to-peer phone consultations. I was surprised to learn how often requests were denied because of NO clinical information. Each and every one of the 8-10 clinical questions were answered “don’t know.” That is like taking a test in school and leaving all the answers blank! Understandably, each of these requests were denied for lack of clinical information, but I was always amazed that the provider’s office employee who called to request an imaging study was not better prepared, better trained, more motivated. This is just one extreme example of many denials and peer-to-peer calls that are rooted in the doctor’s office, but are preventable.
Who is the "Doctor's PAL?
In an earlier post, I introduced a new name for the employee in your office whose job it is to contact the radiology benefits management company (RBM) to obtain prior authorization (PA). I called this individual the “Doctor’s PAL” (PAL stands for Prior Authorization Liaison). This person may also be an insurance clerk, a manager, a medical assistant, a nurse, or a receptionist. The PAL may be clinically trained or not. Because the Doctor’s PAL obtains authorization, they play an essential part in determining whether providers perform many peer-to-peer calls or not. In other words, the PAL’s job performance has a direct bearing on whether you and your office staff are at home in time for family dinner or are still at the office doing P2P calls!
Why is the PAL's job so important?
The key role of the Doctor’s PAL is to make contact with the RBM, either on the phone or via a secure web portal and to answer the RBM’s required questions. The PAL must first answer identifying questions such as the name of the doctor, the patient, and the insurance company. The intake nurse at the RBM will then ask the name of the requested imaging study and the reason for the request. The reason may be a known diagnosis, a suspected diagnosis, or merely the patient’s symptom(s). Based on the answers to the latter two questions, the intake nurse will then ask 8-10 clinical questions taken from the evidence-based guidelines and specific for that diagnosis.
The PAL’s answers to the intake nurse’s questions are critical to the authorization process. If the answers meet the guidelines, the request is approved immediately and an approval number is generated and given to the PAL. If the answers do NOT meet the guidelines, a medical director is brought into the case, and the request is often denied. When the PAL understands the PA process, knows the patient’s history and physical, and can answer the clinical questions, they can achieve a quick approval. It all depends on the PAL’s answers to those clinical questions. It is easy to see how important a well-trained and motivated PAL can be for a physician’s office.
During some P2P calls, the PA or nurse practitioner confided to me that the PAL who called for the original request did not even have full access to the patient’s medical record! This is unfortunate, because without a fully trained and enthusiastic PAL, the RBM can’t get the clinical information needed to make an evidence-based decision, and a denial is almost inevitable.
Your PAL does not have to be Medical School trained!
At this point in the discussion of the PAL, some doctors have asked me if I am suggesting they send their PAL to medical school or at least nursing school. Of course I don’t recommend that. But there’s a lot of middle ground between a medical degree and no medical knowledge whatsoever. A little clinical knowledge focused on a specific patient will open the gates of authorization.
Part of the problem is that the role of PAL is viewed by some providers in a negative way, often because the entire Prior Authorization process is viewed with disdain. If the PAL is trained to view the PA process as an opportunity to make a real contribution to the smooth flow of the entire office, if the PAL is trained in basic coding, if the PAL has full access to the medical records and the evidence-based guidelines, they will see clearly how important the PAL role is. The result will be more approvals “right out of the gate” and fewer P2Ps for providers. In other words, bring your office PAL into the fold.
Post #6 Lesson
A key component to achieving a quick approval is the degree to which the PAL is incorporated into your clinical team. The PAL should be aware of the patient's signs and symptoms, prior lab tests, prior x-rays, and the doctor's suspected diagnosis. The PAL should also have access to guidelines, basic coding, and the questions that they will be called upon to answer. Only by being prepared and communicating clearly and succinctly can the PAL obtain authorization quickly that keeps you, the provider, from having to do those time-consuming P2Ps.
What are other ways to obtain authorization “right out of the gate?” The next posting will give suggestions on how to learn the clinical questions that will be asked even before the phone call begins6