Insurers are denying prior authorization requests at an alarming rate, and that means your patients can’t get the care they need — and you don’t get paid for your services.
A new report indicates that inpatient prior authorization denials are up 26%, while prior authorizations and precertification’s for outpatients rose 16% between 2021 and 2023.
If you’re hoping to avoid seeing your prior authorization requests get denied, check out three tips that may help you improve your odds of success.
1. First, Read the Payer Policy From Beginning to End
Your practice may have a list of procedures requiring prior authorization committed to memory, but your memory can’t always keep up with payer policies. For instance, even if you remember that in 2023, all knee replacements required prior authorization, that may not be the case in 2024. Check every local coverage determination thoroughly before submitting a prior authorization.
These LCDs should provide information about which services require prior auth or precertification, as well as what details they want to receive with your request. They may want to see that your patient already tried more conservative methods to alleviate pain, for instance, before approving a spine surgery, and if you don’t submit those details, you’ll be heading for denial.
2. Know Your Payer’s Preferred Prior Authorization Method
This may seem obvious, but billing experts say that a large proportion of prior authorization denials stem from practices sending the request to the wrong place. And because every payer — and even different MACs — have different preferred methods of receiving these requests, it’s not difficult to route yours to the wrong place.
For instance, your Medicare payer may want prior auth requests to come in through their secure portal, while your Blue Cross plan may want to receive these via fax. If your insurer doesn’t have a preferred method, choose the one that’s most convenient for your practice so you’re sure to submit these efficiently and swiftly.
3. Ensure Two Point People Are Involved
Your practice should have a designated staff member assigned to handle prior authorizations, but you should also have another team member who checks them before sending them out. This backup plan of employing a two-step method will help you eliminate issues before those prior auths go out the door.
Common things that your secondary internal reviewer might catch include incorrect diagnosis or CPT codes, failure to attach documentation when needed, missing fields on the prior authorization form, or a date of service for your planned procedure. If your reviewer tends to catch the same issues repeatedly, they should develop a checklist so the point person can confirm beforehand that they’ve checked all those issues prior to sharing the authorization form with their teammate.
If the burden of handling prior authorizations and precertifications has worn you down, you aren’t alone, but there are experts who can help. Healthcare attorney and compliance expert Osato Chitou, Esq., MPH, will provide you with the tools you need to get your prior authorizations through accurately during her online training Prior Authorization Final Rule: Tactics to Fight Back and Win. Register today!
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