In our first two blog posts on how to avoid peer-to-peer (P2P) phone conversations, we shared some tips on how to make the process of obtaining prior authorization easier and more efficient for clinicians and administrators. The best way to avoid denials, appeals, and P2P phone conversations is to obtain prior authorization “right out of the gate” when your office’s prior authorization employee (PAE) makes the initial request for an approval number. During the initial request before the case is submitted, is the best time to thoroughly gain an understanding of the evidence-based guidelines eviCore uses to determine medical necessity, reference the quick reference tools available, and verify that all documentation validating compliance is complete. Our goal in these blogs is to provide you with the tips, tools, and other necessary information to make the process easier for everyone.
One important tip is that utilizing the eviCore web portal is the fastest, easiest, most efficient way to obtain prior-authorization. While it is important to have all the relevant information prepared prior to initiating a request, utilizing the website takes approximately 3-5 minutes, as opposed to speaking with a representative on the phone.
Here is how our prior authorization process works, using an example of an imaging study.
When the PAE contacts eviCore to request a case or initiates a case through the web portal, our phone representative conducts a quick identification. We identify the patient, the insurance company, the imaging facility, the imaging study, and the reason for the request. With this completed, the case has the potential to be auto-approved after minimal information is provided. If the case is not auto-approved, the PAE is transferred to a nurse reviewer who then asks a series of relevant clinical questions.
eviCore uses an automated decision support system that analyzes the PAE responses to the clinical questions. At times, the system will approve the request based on only a few of the responses. Other times, the nurse reviewer will enter all of the clinical responses into the patient’s data base. While the nurse is typing the answers, he/she is also comparing the responses to eviCore’s evidence-based guidelines seen on another computer screen.
There is nothing magical or secretive about the clinical questions. They are the “who, what, when, where, and how” questions that most providers were taught in school: “What is the problem (e.g., pain, swelling); when did it begin; where is the problem located; how did it occur (e.g., injury, fall, trauma)? The nurse reviewer may also ask if any other imaging studies (x-ray, ultrasound, ECG) have been completed; when the patient sought treatment; what kind of treatment was given; and how long the treatment lasted. For many suspected diseases, the typical questions are available on the eviCore website.
It’s important to understand that eviCore intake nurse reviewers are able to approve any imaging study requested, but they are not authorized to deny any study. If the clinical responses meet the guidelines, the nurse can approve the request immediately and issue a Prior Authorization (PA) number. If the responses do not meet the guidelines, the nurse specialist must pass the case on to one of our medical directors for review. For example, if the guidelines call for a plain x-ray before a CT chest and the PAE does not have the result of the x-ray, the nurse specialist cannot approve the request and will then send the case to a medical director.
Once a medical director reviews the case, his or her options include:
1. Approving the request.
2. Denying the request and providing a reason for the denial.
3. Denying the request and providing an alternative recommendation (alt-rec) – a reason must be given as well.
The difference between a denial and an alt-rec is simple. The alt-rec denies the requested study but offers an alternative imaging study that eviCore will approve. For example, the alt-rec may indicate, “We cannot approve the CT chest without and with contrast, but we will approve a CT chest with contrast only.”
If there is a denial with an alt-rec, eviCore will call your office and offer the alternative imaging study. If it is accepted, the denial is overturned, a PA number is issued for the alternative study, and that number is given to your office staff.
If there is a denial where an alt-rec is declined by the provider’s office, an array of appeals and reconsiderations are allowed, all of which require submission of additional clinical information. The most time-consuming of the appeals involves conducting a P2P phone call, in which a provider must speak on the telephone with a medical director. Again, the P2P may result in upholding the denial; issuance of a different alternative recommendation; or the denial may be overturned and approved, based on the exchange of clinical information between the provider and medical director.
Take Home Point #3: The fastest and most reliable way to avoid P2P phone calls and other appeals and obtain the prior authorization number “right out of the gate” on the very first submission is to be prepared to answer the clinical questions that will be asked.
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 our other tips as part of the “How Can I Avoid Peer-to-Peer Phone Calls” series here. For questions regarding this topic, please email firstname.lastname@example.org.