Friday, September 16, 2011

Hitting a Brick Wall

Have you ever dealt with someone who would not compromise or budge to help you? This recently happened to me. Even though it made me very angry and frustrated, it taught me a valuable lesson. There are going to be times in our professional and personal lives when someone is not going to work with you, no matter what you do. When this happens, there are things you can do.

1. Walk away from the situation for awhile. Give yourself time to think about what can be done.

2. Don't argue with them. It just makes the situation worse. At this point, they are not going to be reasonable anyway.

3. Don't take it personally. There are going to be people out there who will not see things your way no matter what.

4. And if all else fails, go along with what has to be done. Put it behind you and move on.

When I was a clinical reviewer, there were times when I had to follow my company's guidelines in order to precertify a radiology test. If I didn't, I faced consequences, perhaps jeopardizing my job. But I treated each caller with respect, even though they would sometimes be very frustrated and angry. For me, it would always come down to the patient. I would imagine that every patient could be one of my loved ones. That helped me to be empathetic. It helped me to compromise and find other solutions. Because, I didn't want to be someone else's brick wall.

Sunday, September 4, 2011

AMA Survey from 2010 Still Relevant Today

I was searching through some of my old articles on prior authorization/precertification for radiological studies and found this article in 2010 from AMA pertaining to RBMs (Radiology Benefit Managers). As I was reading through the article, the same issues are still relevant today. What struck me was the statistic that 1/3 of physicians experience a 20% rejection rate on their first request for prior authorization of tests and procedures. As a former senior nurse reviewer for one of the largest radiology benefit managers in the country, I can attest this statistic is true. The reason for this is simple. Most callers, specifically medical office staff requesting prior authorization were not prepared to give clinical information or the clinical provided was incomplete. Most people reading the AMA article would think, "Well, the insurance company is just denying them". No, that is not true.  Speaking with medical office staff on the phone, I witnessed this day after day. And I would think to myself, someone needs to teach them how to do this! Of course, that is where my idea of becoming a nurse consultant began.
Yes, the prior authorization process is frustrating. Frustrating for the nurse reviewer and the medical office staff when the clinical given is not sufficient to approve the test/procedure. But there is a solution; train medical office staff how to properly and efficiently obtain prior authorization for advanced imaging.