Easing Prior Authorization for Advanced Imaging

Prior authorizations continually rank as one of the top administrative burdens on physicians.¹ While they can be a hassle, and are perhaps used for too many medications and procedures, prior authorizations are an important tool for managing advanced imaging, which is one of the leading causes of high health care costs in the U.S.²

As a radiology benefits management clinical reviewer and a supervisor of reviewers, we would like to share some tips to help our fellow physicians avoid that dreaded peer-to-peer call request, prevent clinical denials, and generally make prior authorizations less burdensome.

There is often a simple explanation as to why the study you ordered for your patient didn’t get approved. Here’s what can go wrong and how to prevent it.

Documentation not sent. You may have documented everything necessary for pre-authorization, but if you or your staff don’t send that documentation to the reviewer, it is not possible for the reviewer to make the determination. The clinical reviewer assesses whether your request is medically necessary by comparing your notes with widely accepted, evidence-based clinical guidelines. (Ask the insurer for a link to their guidelines, if needed.)

Documentation sent but incomplete. If your imaging request is assigned a peer-to-peer status, then the reviewer has likely concluded that your documentation does not support your order. A peer-to-peer call is an opportunity for you to supply clarifying information. Make sure your staff sends over the correct supporting documents with completed, signed visit notes, not preliminary or incomplete notes. To support medical necessity, be sure your documentation includes key details such as relevant signs and symptoms, relevant lab or other test results, physical exam findings, prior failed treatments, contra-indicated treatments, or prior reports (for repeat studies).