Prior Authorization denials can be a problem for Pain practices trying to treat patients needing interventional pain management treatments. These insidious denials can erode practice revenue and performance if not taken seriously. The matter may become even more critical as CMS contemplates adding prior authorization requirements in the future.

After reviewing our Pain practice client performance, we noticed that practices that document and follow Prior Authorization Checklists fared better than those that do not.  I discussed with our experienced billing teams the best practices to avoid Prior Auth denials and put together these checklists and key lessons learned below to avoid these unnecessary denials.

What are best practices to avoid Prior Authorization or other denials on Interventional Pain cases?

• Prepare an overall plan and policy for handling insurance and prior authorization matters before any procedures are scheduled.
• Identify and list the plans your practice encounters the most.
• Be proactive and understand the payer policies that cover your procedures.
• Request specific reimbursement rates from each payer.
• Build an easy-to-follow table for your staff that includes contact information and list of procedures that require an authorization.
• Train your staff to ensure they are well-versed on the procedures you perform along with the most commonly associated CPT and ICD-10 CM codes.
• Create a process to ensure all correct information is gathered at the time of scheduling.  If any key information is missing, the procedure should be rescheduled.
• Know your denial rate.  Due to the fact most payers have a well-defined payment policy for diagnostic and interventional pain treatments, it is not unreasonable to expect a 0% denial rate!
• Due the fact most commercial and Medicare payers have varying medical necessity policies, it is important to review each payers’ specific policy, at least annually.

Create a checklist for your staff to follow for all patient encounters. Key steps include:

• Obtain complete insurance information from the patient and scan insurance card into EHR/PM.
• Before requesting Prior Authorizations, confirm the patient’s insurance eligibility and pain-specific benefits and that the intended procedure is a covered service.
• Request Prior Authorizations on every procedure, regardless of payer.  Payers change their rules frequently and typically don’t communicate such changes effectively.  It’s better to be safe than sorry.
• Be very specific on Prior Authorization requests.  Include the following: Date of service, Reason for the procedure including the ICD-10 code and explanation of medical necessity. CPT codes of procedures you plan to perform.
• Ensure that the DOS, ICD-10 and CPT codes approved on the Prior Authorization are identical to those billed.  If not, payers will likely deny the claim.
• Choose CPT codes that are specific to laterality, if applicable.  Payers may deny the claim if the laterality approved does not match that which is billed.
• Get a hard copy of the Prior Authorization approval from the payer.
• Immediately notify the payer if the actual procedure performed is different than the one authorized and be prepared to explain the reason for the change.
• If necessary, request a Retro Authorization immediately on the date of service.  Later attempts are typically unsuccessful.
• Providers must include clear and complete documentation in the provider’s note explaining what procedure was performed, how it was performed, and why it was medically necessary.  Insurance companies require supporting documentation for denial appeals and it is important that such documents are easily retrievable and prepared for appeals.   High quality documentation is typically the most effective weapon a practice has to win in any appeal process.

Special Reminder – Before requesting a prior authorization, confirm the patient’s insurance eligibility and pain-specific benefits and that the intended procedure is a covered service.  It is possible to get a prior authorization yet still have your claim denied because the patient was not eligible for the specific procedure.  Payers often do not check this before granting a prior authorization, so you must do it every time.

For more information on this and other topics important to Pain Clinics, please see www.streamlineMD.com or contact your StreamlineMD client representative.