Tips for Obtaining Prior Authorization

Obtaining prior authorization is a daily challenge for many health care professionals. Rachel Decena, a health care claims specialist with Amazing Healthcare Consultants in Birmingham, MI, shares her tips for expediting the process.

Check Requirements in Advance
Payers typically send health care professionals a hard copy of their handbook that includes guidelines for what the insurance plan will cover. If a hard copy isn’t available, then Decena advises physicians or administrative staff members to call the payer before beginning the prior authorization process. Ask for their rules for the specific procedure and diagnosis codes. “Before you even start, it’s good to know what guidelines the insurance [company] is looking for—it could save a headache,” Decena says.

Follow Up Regularly
When faxing a prior authorization request, Decena recommends following up the next day to confirm that the payer received the form. It can take 24 to 48 hours for prior authorizations to go through, depending on the insurer and the submission system. Set a reminder to follow up after that time because not all billing software programs automatically send reminder alerts.

Optimize Your Workflow
If your office doesn’t already have an effective workflow in place for keeping track of prior authorization requests, then consider using a new organizational method such as a physical spreadsheet. “You have to be very organized if you’re the one who’s doing the prior authorizations in the office,” Decena says.

Establish Protocols
Obtaining prior authorization over the phone isn’t always efficient. In lieu of sitting on hold, Kenneth Greene, MD, an internist in Baltimore, MD, asks his staff to request the necessary prior authorization forms from payers. “If it’s more than just a few questions, we ask [insurance companies] to send us a form so we can do the research we need to do, fill in the information, and fax it back,” Greene says.

Make an Effective Appeal
The appeals process for a denied prior authorization request can be cumbersome. If payers issue a denial, then many allow physicians to request a peer-to-peer review first, eliminating the need for an appeal. If a peer-to-peer review isn’t an option, find out why the prior authorization was denied, and then confirm the payer’s appeals guidelines and the necessary documentation to support an appeal. Depending on the reason for denial, an alternative treatment option might be more expeditious for the provider and the patient.