Prior Authorization For Advanced Imaging - A Nurse Reviewer's Perspective

Many insurance companies now require prior authorization for advanced imaging (MRI, CT, PET scan and Nuclear Medicine) and providers are being tasked with conforming to this process. What this means in most cases, is that the physician's office must now delegate a staff member or even create a department to handle prior authorizations. As a former senior clinical reviewer for one of the largest advanced imaging management companies, I saw firsthand many of the difficulties faced by staff and how they struggled with this process. 

The prior authorization process starts with either a phone call, fax or accessing a web site to provide patient information. They must also provide the imaging study requested with a CPT code and clinical information. For most health plans, a clinical reviewer, usually a nurse, will initially review the clinical provided. It is matched to specific criteria or guidelines set forth by the American College of Radiology and/or physician specialists. If after reviewing the clinical and the case is approved, a prior authorization number is given. If it cannot be approved, it is sent to a physician for further review. The physician may request additional clinical or deny the study. If the study is denied, there is usually a first and second level of appeals depending on the health plan.

From the time the case is started to the final outcome, there can be obstacles along the way that could cause a delay in the prior authorization. A few of the most common will be discussed. Delays increase the amount of time a staff member or even the doctor has to spend working on the prior authorization. It means that the patient must wait before the test can be performed.

Providing an incorrect diagnosis or rule out may cause delay. If the clinical provided does not correlate to the study being requested, it is then forwarded to a physician for further review. Therefore, it is extremely important that this information is correct. And if a staff member is unfamiliar with disease processes, this could easily occur. For example, using a diagnosis of liver mass when the physician is ordering an MRA abdomen to rule out renal artery stenosis. Along the same line, if an incorrect CPT code (billing code which correlates to the test being requested) or imaging study is given, it may also cause delay. Most often it is corrected right away by the nurse reviewer, but not always.

Providing clinical is the biggest challenge for most staff. This can include symptoms, physical exam findings, medications and/or treatment with duration, prior test results and medical history. 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 nurse reviewer can sometimes be confusing, even foreign to a non-medical person. Couple that with the inability to decipher the physician's note, laboratory and special testing and you can see how the prior authorization can be delayed, even denied.

There are changes that must take place in order to avoid these delays and denials. Non-medical office staff must have training and education. Unfortunately, there is little information and no formal training provided by the insurance companies or advanced imaging management companies to prepare staff on how to maneuver through this process. This is the solution that will save time, money and frustration, as well as improve patient care.