My Article on Prior Authorization

Prior Authorization For Advanced Imaging - A Nurse Reviewer's Perspective
By Terri Richards, RN, BSN

Many health insurance companies now require prior authorization for advanced imaging(MRI, CT, PET scan and Nuclear Medicine studies) and medical providers are being tasked to conform with this process. Some health insurance companies have contracted with a radiology benefit manager(RBM) who is responsible for collecting the clinical information and rendering a decision to approve or deny the test. This is a means of controlling costs and managing utilization. What this means for the medical provider is that they must now delegate a staff member or even create a separate department to handle prior authorizations. As a former senior clinical reviewer for one of the largest radiology benefit managers in the country, I saw firsthand many of the difficulties faced by medical office staff and how they struggle with this process.

The prior authorization process starts with either a phone call, fax or accessing a website to provide patient information, the imaging study requested, CPT code and clinical information. The clinical reviewer, usually a nurse, will review the clinical information and match it to specific criteria based on guidelines set forth by the American College of Radiology, clinical practice, radiologists and physician specialists. If after reviewing the clinical and the test is approved, a prior authorization number and expiration date is given. If it is not approved, it is forwarded to a physician(medical director) for further review. They may approve the test, request additional clinical, suggest another test or deny the study. If the study is denied, there is an appeals process, usually a first and second level of appeals depending on the health plan.

From the time the case is started to the final decision, there may be obstacles along the way that can cause delay. This can increase the amount of time the medical office staff or even a medical provider has to spend working on the prior authorization. It means that the patient must wait before the test can be performed if it is non-urgent.

Reasons for delay or denial include giving an incorrect diagnosis/rule out or providing an incorrect CPT code or imaging test. If the clinical provided does not correlate to the guidelines or criteria for that particular test, the clinical reviewer will forward the study to a medical director for further review. And if a medical staff member is unfamiliar with disease processes, this could easily occur. For example, using a diagnosis of kidney mass when the physician is ordering an MRA abdomen to rule out renal artery stenosis. Most often it is corrected right away by the clinical reviewer, but not always. Therefore, it is extremely important that this information is correct.

Providing the clinical is the biggest challenge for most staff. Most often, it is non-medical staff that provide clinical, as these are the most common staff members tasked with obtaining prior authorization. The medical questions asked by the clinical reviewer can sometimes be confusing, even foreign to a non-medical staff member. Couple that with the inability to decipher the medical provider's note, laboratory and special testing and you can see how the test can be delayed or even denied.

There is little information available to prepare staff on how to maneuver through this process. Health insurance companies and radiology benefit managers do not provide any comprehensive training for medical office staff to teach them how to provide clinical and to avoid the most common mistakes. Proper training would save time, money and frustration, as well as improve patient care. More importantly, the patient would get the right test at the right time without delay or hassle.