Tracing the Path and Significance of Prior Authorization

Health insurers require prior authorization (PA) for certain healthcare services, treatment plans, prescription drugs, and/or durable medical equipment before a patient can receive them. The determination focuses on whether the service, drug, or product is medically necessary. It does not guarantee that the insurer will cover the cost.

The PA process—and research into its effectiveness—dates back more than 25 years, when states began analyzing how to curtail drug costs within the Medicaid program. The Omnibus Budget Reconciliation Act of 1990 included PA among explicit provisions for limiting drug coverage and cutting costs. The legislation also required the Health and Human Services Secretary to study the impact of PA programs on beneficiary and provider access to prescription drugs as well as on program costs, and to make recommendations for PA reforms if needed.

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When Does Medical Testing Become Unnecessary or Even Harmful?

Recently, well-known bioethicist Arthur Kaplan and his fellow researcher, radiologist Dr. Stella Kang, raised an important question: Does the growing tendency to offer more and more medical tests inadvertently harm some patients?

“How can radiologists fulfill the ethical obligation to support patient interests when very low-risk incidental findings concern patients for different reasons and lead to excessive resource utilization?” wrote Kang, Kaplan and other researchers from NYU Langone Medical Center in the Journal of the American College of Radiology.

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Prior Auth Needs Improvement (there, we said it)

As a doctor, your work day is full of challenges. The truth is, we understand that the old way of managing prior authorization can be cumbersome and inefficient. So that’s why we are changing things. Watch our video below to find out more about how eviCore is working to streamline the entire utilization management process and make it easier for you to give your patients the best care possible.


Tip #2:”How can I Avoid Peer-to-Peer Phone Calls?”

The question most often asked by providers during peer-to-peer (P2P) telephone conversations continues to be “How can I avoid doing so many peer-to-peer phone calls?”

The most obvious (yet also the most accurate) answer to the question of minimizing P2P calls is, “By providing the clinical information to clearly support approval on the very first submission.” While it is true that any imaging study not initially approved can be appealed, the process runs much more smoothly if eviCore receives the most relevant clinical information at the beginning of a case. The tasks associated with all appeals are time consuming, even the simplest fax to request additional clinical information. By providing supporting clinical information to eviCore, during the initial phone call or Web portal interaction, should enable rapid approval.

For example, if guidelines for an MRI for chronic knee pain (to rule out a meniscus tear) call for a recent plain x-ray and six weeks of conservative therapy, it is much more expedient to make sure the patient has had the x-ray and conservative treatment before requesting the scan. If your “prior-authorization employee” gives us the dates of treatment, a description of that treatment, and the result and date of the x-ray, the entire process need only take a few minutes, and no lengthy P2P call is needed.

eviCore understands that clinicians have a huge demand on their professional time, and we want to lessen the burden for everyone involved. In the coming months, this blog will be dedicated to giving you advice and tools that you can use to reduce denials, appeals, and P2P calls. We also ask providers and office staff to email us suggestions and questions that may help us make the entire prior-authorization process run more smoothly for everyone.

Take Home Point #2: To avoid denials and P2Ps, be proactive; anticipate and prepare the clinical information that eviCore will likely need, and provide that information to your prior-authorization employee to get approval during the initial request. 

Author: Robert L. Neaderthal, M.D.

Robert L. Neaderthal, M.D. has been a medical director at eviCore healthcare for seven years. Prior to joining eviCore, he served for 30 years as a primary-care internist in Nashville, Tennessee. Since joining eviCore, Dr. Neaderthal has been committed to helping other providers avoid peer-to-peers by educating them on ways to avoid denials.

For more tips on how to avoid peer to peer phone calls, read Tip 1 of the “How Can I Avoid Peer to Peer Phone Calls” series here.

Tip #1 “How can I Avoid Peer-to-Peer Conversations?”

Before becoming a Medical Director for eviCore healthcare seven years ago, I had the privilege of serving for 30 years as a primary-care internist in Nashville, Tennessee. My last few years of private practice were during those early years of prior authorization, when only a few insurance plans required approval for advanced imaging studies (CT scans, MRI scans, PET scans, and nuclear cardiac studies). In my first few years as a Medical Director, I was surprised at how many requested imaging studies were being denied — even for what appeared to be routine studies — and how often peer-to-peer (P2P) phone conversations took place. Since then, I have been committed to helping other providers avoid peer-to-peers by educating them on ways to avoid denials.

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