Most non-medical staff designated to do prior authorization for advanced radiology(MRI, CT, PET scan, nuclear medicine) are not trained. Due to staff shortages and administrative cost cuts, non-medical staff are tasked with performing prior authorizations. An internist, Dr. Hoffman from Oregan, in a recent article posted in the American Medical News, stated, "a recent Health Affairs article put the problem into perspective with a report that each U.S. physician spends, on average, $70,000 each year resolving insurance-related issues". Specifically, the prior authorization process can be confusing, especially for non-medical staff. Providing incorrect clinical information, the lack of clinical information and incorrect CPT codes, just to name a few of the many errors I have witnessed with medical office staff as a former nurse reviewer, can easily lead to delays and denials.
Another article from Diagnostic Imaging, Nov 2008, quotes Dr. David Steinberg, Steinberg Diagnostic Imaging in Las Vegas, NV, "Primary care physicians, in particular, are feeling the strain of flat reimbursement and rising costs. With crowds of patients in their waiting rooms, they cannot afford to spend uncompensated time on the phone". How can this be avoided? By training your staff to perform this function efficiently and timely. My training program can help you reduce the amount of time spent by medical staff to deal with insurance company requests for advanced imaging.
Another way medical offices are dealing with the pressure of obtaining prior authorization is to fabricate information. Another statement from Diagnostic Imaging states, "Physicians can corrupt the system by learning and reporting the clinical criteria that produce an approval, even when the patient's indications don't actually apply to the case. One source said that he knew of a referring physician who prepared cue cards to guide a secretary as she input orders into the prior authorization system. Others say physicians who engage in in-office imaging tend to repeatedly order the same applications, which allows them to memorize the key words that secure approvals". This is not the situation you or your staff wish to be in. "RadAlert, a MedSolutions program, working transparently with the firm's prior authorization program,the software applies management-by-exception principles to physicians who are suspiciously adept at securing authorizations. Unusual behavior leads to chart reviews and corrective action. Some have been turned over to the fraud unit of the cian's contract after learning about the behavior," Farnsworth said as described in the Diagnostic Imaging article. And trust me, you do not want to be subject to corrective action.
Contact me today to discuss how I can train your staff, avoid costly delays/denials and decrease staff frustration with this process.