The complexity of prior authorization runs deep

I appreciated reading about the efforts to improve the authorization process (“Where to start in fixing prior authorization,” Oct. 7, p. 18). While the article addresses the clinical issues involved in obtaining an authorization, it does not address the lack of additional non-clinical workflows that are required.

In my 25-plus years as a revenue cycle consultant, my impressions are that in many instances, the payers tell the provider that there is no authorization required, the claim is submitted, then the claim is denied for lack of authorization. But there is more.

There are two non-clinical issues to address: whether the provider performed the same service as requested on the authorization and a lack of updated, internal information for payer employees to rely on when answering the question of whether a prior authorization is needed.

Providers must have a system, automated or manual, that looks at the actual service CPTs that were provided the day after a procedure or service was performed and determines whether the service changed or additional services were provided. When this comparison shows differences in what was provided versus what was requested for the authorization, patient access must immediately contact the payer to update the services provided. Also, if it was first determined that the procedures or services for a patient didn’t require an initial authorization, then their actual care must be reviewed to determine if, because of changes to the services, an authorization is now required.

At one of my clients, a large health system with a high number of denials for lack of authorization, we took a different tack. We had all of the notes that detailed the authorization request in the system; however, this provided no proof for staff to appeal the denial. We installed recorded lines for every staff member that requested authorizations so that we could go back to the payer and prove to them what they previously said. Then we tracked this specific type of denial for three months. We annualized the payer data and requested that they reprocess the denials going back 18 months or whatever their billing limitation was. Most complied faced with the evidence. For those that didn’t, we sent a letter with our evidence to the state insurance commissioner.

Most hospital systems and medical practices do not perform a comparison review after the services are provided. This takes more manpower, but I do believe that simple feasibility calculations will warrant additional staff until an electronic solution is available. The process for obtaining authorizations in the home care industry is even more complex and would benefit significantly from an overhaul of procedures.

Claudia J. Groenevelt Atlanta