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.