How to Get Medical Pre-approval or Prior Authorization Effectively

Health insurance companies use the preauthorization process to verify whether a drug, procedure or service prescribed is medically necessary.

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Dealing with prior-authorization is crucial as it effectively improves patient outcomes by ensuring that they receive the correct medications when they need them, thereby reducing unnecessary prescription drug usage. Pre-authorization/Prior authorization/Pre-approval – is an authorization that health insurance companies require plan members to obtain before receiving any specific type of care. Health insurance companies normally require prior authorization for medications, durable medical equipment (DME) and medical services, and insurance authorization services are available to help handle the administrative burden associated with the process. By pre-authorizing a service, treatment plan or procedure, your insurance carrier is not only agreeing that the healthcare procedure recommended is medically necessary, but also ensuring that maximum reimbursement will be met for the procedure.

Which Services Require Pre-approval?

Most procedures that require pre-approval go well beyond the routine care provided by the primary-care physician. Some of the common medical procedures and services for which insurers typically require pre-authorization or written approval include – •

Surgical procedures

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Radiology services (X-ray, MRI, CT or PET scan, ultrasound)

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Pain management services (nerve blocks, trigger point injections, a host of others)

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Non-emergency ambulance services

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Home care services (home therapy, hospice, skilled nursing visits)

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Gastrointestinal tests (endoscopies, CT colonoscopies)

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Durable medical equipment

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Specialty drugs provided in certain situations

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Sleep studies (to diagnose sleep disorders)

Inpatient hospital services are also subject to pre-approval, although they go by a different name. For instance, if your physician want to admit you for a non-emergency hospital stay, it is important to obtain pre-admission certification. On the other hand, pre-admission certification is not required for emergency hospital stays.

Writing the Prior-authorization Letter – General Guidelines The pre-authorization process can be initiated by sending a pre-authorization letter to the concerned medical insurance company. Although there are general guidelines to write a pre-

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authorization letter, each company has varied requirements depending upon its individual policy and procedures. Here are some important details required for all prior-authorization letters – •

Demographic information of the patient (Includes - Name, date of birth, insurance ID number and more)

•

Provider information (both referring and servicing provider) o

Tax ID number

o

National Provider Identifier (NPI) number

o

Address where services are being rendered

o

Phone and fax number



Requested service/procedure along with specific CPT/HCPCS codes



Location where the service will be performed

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Length of stay requested in case of inpatient requests

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Diagnosis (ICD code and description)

Along with this letter, it is important to submit all medical notes. Based on the coverage policy and the complexity of the service, it is essential to submit all additional information such as previous treatment history and clarification on the type of service provided. With accurate

and

timely

submissions,

your

pre-authorization

request

will

be

clearly

communicated to the insurance company and they will in turn process the request quickly.

Obtaining Pre-authorization and Preventing Denials – Important Steps Here are some important steps that physicians can take to obtain pre-authorization and prevent denials – 

Know about the coverage and preauthorization guidelines – Physicians must be well aware about the coverage and pre-authorization guidelines of each payer and provide the specific diagnosis on their reports. The diagnosis codes reported tell the payer “why” the specific service has to be performed and helps support the medical necessity of the procedure.

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Follow treatment guidelines - Physicians should ensure that they are following the correct recommended treatment guidelines before recommending a high-cost procedure for a patient.

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Meet all payer criteria – Prior to submitting a pre-authorization request, providers need to check whether they fulfill all the payer’s criteria.

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

Regular monitoring of insurance carrier websites – Monitoring insurance carrier websites on a regular basis is crucial as it will help patients identify crucial issues affecting them so that they can bring it to the notice of their insurance carrier and advocate for themselves and their provider.

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Update contracts with insurance companies - Insurance companies may update their coverage policy from time to time and therefore providers need to track these changes and update their contracts to maintain coverage.

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Take steps against denials – Healthcare providers should have relevant information about the specific procedures performed and must have adequate evidence to prove that the medical necessity of the specific procedure and details on coverage for certain diagnoses. Such information would also help during reimbursement negotiations.

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Conduct regular audits – Regular audits can detect potential issues and help identify denial trends for certain procedures. Thus providers can correct minor issues that may be responsible for a large portion of the denials. In addition, audits should also focus on diagnosis codes and final payment.

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Know the diagnosis codes – This is primarily important for orthopedic and spine procedures as many do not have clearly defined codes. The help of a reliable and experienced medical billing and coding service provider can prove to be useful when negotiating contracts and seeking full reimbursement for certain highvolume codes under diagnoses.

It is estimated that prior - authorization and medical necessity related denials account for more than 11% of all denials, and usually occurs due to failure to secure an authorization in advance. The process of authorization starts with procedure-specific policies crafted and managed at the payer, plan, employer, and group levels. Insurance companies have insurance verification specialists who can help providers with the process of obtaining preauthorizations. Partnering with a reliable insurance authorization company helps healthcare practices minimize the time and resources required for getting prior authorizations, reduce the risk of denials, benefiting both physicians and patients.

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