The doctor orders an MRI, CT, PET scan or nuclear medicine scan for their patient. The paperwork is given to medical office staff to get prior authorization, aka precertification from the health insurance company. You call in and give the medical insurance information, study requested, CPT code, diagnosis, demographics of the patient, site and medical office. Then you are transferred to a clinical reviewer, usually a nurse. Questions are asked about the patient's medical history, signs and symptoms and physical exam findings just to name a few. This is where most medical staff have problems. The answers to these questions will determine if the test is needed. If it is not immediately approved, the case is sent for review to a medical director, who is a physician for the health insurance company. This can take up to two business days if it is not medically urgent. If the medical director asks for additional information, add about another two days for the medical office to respond. Add about another two days for the medical director to make a final determination. In the meantime, you are waiting for an answer. The patient is waiting to have their test done. This is frustrating for everyone involved. It is my experience that 1 out of 3 medical office staff are unable to provide complete clinical. This results in an automatic medical review.
This is where I can help you. No matter what experience you have had with prior authorization, you can benefit from my educational program. I can teach you how to be a "pro" at providing clinical, understanding the study being requested and give many, many tips on how to avoid the red tape and help you to be more efficient in this process. Contact me today to talk about how I can help you right now.