Post#7 How Obtaining Prior Authorization is like taking a Quiz

While working as a medical director for a Radiology Benefits Management company (RBM), I discovered a pattern repeated over and over again that leads to denied imaging studies and peer-to-peer calls (P2P).  The great majority of P2P calls that take place between providers and medical directors end with overturning and approving the imaging request. The simple exchange of clinical information on the phone nearly always provides data not obtained during that first phone call with your office staff.  This new information fulfills the guideline criteria and convinces the medical director to approve the imaging study. That makes sense, speaking with the provider who has examined the patient is almost always more helpful than speaking with the doctor’s surrogate who places the initial request call.  After all, who knows the patient’s clinical information better than the provider? 

Previously I have referred to the office employee who places the initial call to the RBM as the “Doctor’s PAL” (which stands for Prior Authorization Liaison).  Denials result when the PAL has not been given complete or accurate clinical information.  The essential secret of avoiding P2P calls is improved communication between the provider and the PAL so the PAL can obtain authorization “right out of the gate.” 
 Think of the initial request for an imaging study as a type of Quiz.  

The RBM intake nurse asks the PAL 8-10 clinical questions that make up the quiz.   How well the PAL answers those questions will determine the success in obtaining approval for a CT or MRI or other imaging study.  The penalty for failing to answer the questions falls to the provider who must then perform a lengthy and wasteful P2P call.
 Clearly, the PAL may not be as familiar with the clinical case as the provider. When the PAL doesn’t know the answers to the Prior Authorization quiz questions, the request is denied and the provider must spend precious time on the phone appealing  the decision. 
Therefore, it is the responsibility of all providers to prepare the PAL to answer the questions that meet the criteria found in the guidelines. 
 How do you make certain the PAL is prepared for the Prior Authorization ‘Quiz?’
Providers should make certain that their PALhas full access to the patient’s medical record and
·      has access to the RBM evidence-based guidelines
·      knows enough about X-ray coding to order the correct imaging and contrast study
·      has been given sufficient clinical details for the specific patient to answer the questions                 before calling for approval.
How does the PAL find the questions and answers to the Quiz?
Just like with any quiz in school, it’s helpful to make a study guide. The 8-10 clinical questions the intake nurses will ask your PAL are ALL taken from the evidence-based guidelines.  Questions will vary with the type of imaging study needed and the reason for the request. For example, an imaging study to diagnose appendicitis will have a different set of questions than those for imaging to diagnose diverticulitis. But all the answers can be found in the guidelines, just by looking up the specific diagnosis.
Here’s a case study: a request for a scan for generalized abdominal pain.  Physicians often request a CT scan, whereas guidelines might support an ultrasound (US) instead.  Guidelines from one RBM states that in most patients an ultrasound should be the initial imaging study unless there are at least one of the following red-flag signs present..
 The Red flags are:
•    Failure of Conservative treatment for 4 weeks
•    Guarding, rebound tenderness, or other peritoneal signs
•    GI Bleeding
•    Moderate/severe abdominal pain
•    Cancer history
•    Tenderness
•    Fever (101 degrees or greater)
•    A mass
•    WBC 10,000 or greater
Guidelines further explain that it would take only one red flag to support a CT as initial study instead of an ultrasound.. In the absence of any red flags, US would be the preferred initial imaging study. 
 The second exception that would support a CT scan is when an US has been already performed but is equivocal or inconclusive.  
 Just by reviewing the imaging criteria in the guidelines, you and your PAL can easily determine which clinical questions will be asked.  Being prepared in advance of that first request call will ensure a quick approval.
There are other reasons the PAL is unable to obtain prior authorization with the first call.   Often the progress notes are not legible.  Maybe a progress note is dictated but not typed into the chart at the time of the PA call.  Providers often have clinical information that the PAL does not have, such as the result of a stat CBC or hemoccult, or a chest x-ray verbal report that is not yet in the patient’s record.  All of these obstacles can be overcome, however, if the provider verbally communicates with the PAL to prepare her for the intake nurse’s quiz questions.  Failure to do this may result in a denial, which will lead to another P2P call.
A great way to avoid denials is for providers to keep a copy of RBM guidelines on their desktop.  When deciding whether to request a CT with contrast or a CT without contrast, or other imaging questions, the guidelines are a good quick reference.  Another tip for your PAL to help study for the quiz with the RBM nurse is to keep a copy of the guidelines on her desktop as well.  This way your PAL is more likely to obtain a quick approval, avoiding that denial which leads to a P2P.  In a previous post (The second key to the Prior Authorization Castle), I describe how to easily copy the guidelines and paste them to your desktop or the desktop of your PAL. 

Lesson: Avoiding P2P calls requires some preparation for the quiz by both PAL and provider.  The PAL can learn the questions (and answers) the nurse will ask merely by looking at the guidelines, while the provider can make sure the PAL is informed of the clinical details for the specific patient that support those guidelines. Obtaining a quick approval by the PAL then becomes a "piece of cake."