Basic Tactics and Prior Authorization Services – Sunknowledge


Prior authorization has in the recent times seen major regulatory changes. The forced changes have made prior authorizations more complex. With the federal decision of withdrawing the Affordable Care Act (ACA), which was popularly called Obamacare, insurance companies have stepped on the pedal in their demand for more documentation requirements for prior authorization requests. Add to it, the onslaught of the Final Rules. In the recent edition of the Final Rule, CMS has mandated prior authorization for certain DMEs, prosthetics, orthotics, and supplies (DMEPOS). The Final Rule requires the establishment of a Master List containing 135 DMEPOS items that must remain on the list for 10 years from the date of addition. Although the aim is to check the rising prices and increase transparency in the process, the technicalities involved have piled up making life difficult for the billing executives of the in-house staffs of various healthcare providers. Often, these in-house billing executives lose track of the proper prior auth process sandwiched between handling patient care and billing responsibilities including prior auths. No wonder, more and more healthcare practices are outsourcing their prior auth functions to professional prior authorization services. However, irrespective of getting the process outsourced or handling all by themselves, a good understanding of the prior authorization process addressing the new requirements will help identify the pain points and a big step towards improving the prior auth mechanism.

Identifying the common rejection reasons is very important as a first step. The reasons mostly held responsible for prior authorization rejections are:

• Faulty Paperwork
• Coding errors
• Information not provided in proper
• Out of coverage service request

Apart from working on the pain areas, it will be always advantageous to keep the following Information can be kept as ready references:

The following general clinical information helps to streamline the request initiations:

o Working diagnosis with the appropriate ICD code
o Details of patient’s clinical condition
o Information on drug
o Duration and dates of tests/procedures
o Requested imaging procedure with the CPT code
o Previous radiology reports
o Treatment received before the requested radiology test

A list of the eligible common Tests/ Procedures is mandatory. Some of the eligible tests are:

o CT Scans
o PET Scans
o X-ray
o Nuclear Medicine/Cardiology

Although the provisions of resubmissions give a platform to rectify the errors and resubmission, it means restarting the process. That incurs additional costs and delays the process further. A thorough monitoring of the prior authorization process and noting down the regular errors and misses help to build a best practice mechanism to counter future mistakes.