Providers continue to wonder how we can live in a world where so many RCM processes are handled quickly with technology, yet decisions that affect patient health are slowed by faxes and bureaucracy, even when there is only one clear treatment option. Yes, you are right, we are talking about Prior Authorization (PA) or Pre-Auth. Need your patient to switch from Coumadin to Lovenox because they have surgery in three days?
Sorry, there’s no way the prior authorization will be approved in time. Just have the patient reschedule and put their health at risk. The problem with a lot of insurance carriers is they change what’s on their formularies, and one day the insulin NovoLog is covered and then the next day it changes to Humalog, and now the patient has to switch and it’s very confusing.
Every insurance carrier has its unique prior authorization requirements, which makes it difficult to automate. As per CAQH, prior authorizations have the lowest electronic adoption rate of any transaction in the healthcare field. In 2019, electronic prior authorizations increased from 13 to 21 percent.
Addition of Two New Service Group
As part of the 2021 ‘Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule’, CMS added ‘Implanted Spinal Neurostimulators’ and ‘Cervical Fusion with Disc Removal’ to the prior authorization process for services provided on or after July 1, 2021.
Practices must obtain prior authorization for the following new service groups:
- Implanted Spinal Neurostimulators: CMS will only require prior authorization when providers report Current Procedural Terminology (CPT®) code 63650. CMS has temporarily removed CPT codes* 63685 and 63688 from the list of services requiring prior authorization and will monitor prior authorization for spinal neurostimulators to determine if it will add additional codes in the future. CMS will only require prior authorization for trial implantation procedures for providers reporting both trial and permanent implantation procedures using 63650.
- Cervical Fusion with Disc Removal: CMS will require prior authorization for claims containing CPT® code 22551 or 22552.
- In addition to the two new service groups above, the prior authorization process will remain in effect for the five groups of services previously identified as high risk for improper payments, including blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation procedures.
Step Therapy
Another prior authorization technique that can drive providers crazy is step therapy, sometimes called the fail-first requirement. Under such a policy, payers will require that patients first try and fail lower-cost tests, drugs, or other treatments before moving on to higher-cost options, sometimes in cases when the patient has already unsuccessfully tried the therapy under a previous insurance plan.
Peer-to-Peer Review
Peer-to-peer review is a process in which an ordering physician discusses the need for a procedure or drug with another physician who works for the payer in order to obtain prior authorization or appeal a previously denied PA. If properly implemented, the process can be helpful, as it affords the physician the opportunity to speak with another clinician. What drives providers crazy is that it usually comes after days or even weeks of bureaucratic wrangling.
Include Required Details
Every payer has a unique form for submitting prior authorization requests. You can add the following details while submitting a PA request to avoid any delays:
- Beneficiary information: Patient name, Medicare beneficiary identifier, and date of birth.
- Hospital outpatient department information: Facility name, provider transaction account number/ certification number (PTAN/CCN), National Provider Identifier (NPI), and address.
- Physician information: The performing physician’s name, address, PTAN, and NPI.
- Requestor Information: Requestor name, phone number, and address.
- Other information: The prior authorization request should include the anticipated date of service, Healthcare Common Procedure Coding System (HCPCS) codes, diagnosis codes, type of bill, units of service, the indication of whether the request is an initial or subsequent review request, and the reason for requesting an expedited review (if applicable).
Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle solutions. As discussed above prior authorization is not a standard process and every payer has unique PA requirements. We can assist you in getting prior authorizations for your practice for various payers.
When we share benefits report for every patient visit, we also check for prior authorization requirements and submit them wherever applicable. To learn more about our prior authorization services, contact us at info@medicalbillersandcoders.com/ 888-357-3226
*CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA)
References:
- The Prior Authorization Process: Need-to-Know Changes for 2021
- 8 prior authorization terms that drive every doctor crazy
FAQs
1. Why is prior authorization (PA) a challenge in healthcare?
Prior authorization is time-consuming due to complex, insurer-specific requirements and the need for approval, delaying necessary treatments and procedures.
2. What new services require prior authorization under CMS rules?
Starting July 1, 2021, prior authorization is required for implanted spinal neurostimulators (CPT code 63650) and cervical fusion with disc removal (CPT codes 22551 and 22552).
3. What is step therapy in prior authorization?
Step therapy, or “fail-first,” requires patients to try lower-cost treatments before moving on to more expensive options, sometimes even when they’ve already failed on the same treatments.
4. How can I speed up the prior authorization process?
Submitting all required details such as patient and physician information, CPT and diagnosis codes, and the requested service date can help avoid delays in the approval process.
5. How can Medical Billers and Coders help with prior authorization?
We assist by checking prior authorization requirements, submitting requests on time, and ensuring all details are correctly included to expedite approvals for your practice.
