The wordy, confusing letters that patients sometimes receive telling them that their doctor's request for a procedure or lab test has been denied can be frustrating — particularly if the patient isn't familiar with prior authorization or doesn't know that it's a requirement for most health plans.
"Each year thousands and thousands of these letters or communications go out from our offices with my name on them, which makes me pretty popular among those who get an approval, but not so much for those who get denials," said Gregg Allen, MD, FAAFP, chief medical officer at eviCore.
Because it can be an unwelcome surprise to receive these lengthy letters, which tend to be scripted according to health and regulatory requirements, we have some tips below on how providers can help their patients avoid them altogether.
Why are prior authorizations denied?
First, it's important to understand some of the most common reasons why prior authorizations are denied, which may help avoid them.
- Need more clinical information
Sometimes the reviewers at eviCore have to deny a request because they need more clinical information from the provider's office to make a determination.
- More conservative therapy must be tried first
Sometimes eviCore needs some demonstration from the patient's caregiver that they have completed an adequate trial of more conservative therapy, such as rest, ice, elevation, or a non-steroidal anti-inflammatory for conditions like joint or lower-back pain. These conditions are frequently benign and self-limited, meaning they get better with consistent simple treatment. So, often patients don't need to be scanned, scoped or have needles injected into them until an appropriate conservative therapy has had time to succeed.
- Lack of precursor or test
The third reason might be that the treatment chronology lacks a specific type of precursor or test — such as an ultrasound or chest X-ray — that should always be tried prior to a more complicated procedure like advanced imaging or surgery. Contraindications for a test might also apply. For example, someone with a metallic implant would be denied an MRI on that basis.
- Clinical question behind request not stated
A provider's request could be denied if they have not clearly stated the fundamental clinical question supporting the request. Patient safety is paramount. While imaging is typically safe for most patients, exposing them to over-imaging risks should be avoided.
"If the indication for the test is not clear, and the patient is going to be exposed to radiation, we need a good reason to do it," Dr. Allen said. "A good-practice question to ask yourself as a provider is, if you're not going to change the way you manage the patient, treat them, or follow up with them as a result of the diagnostic test you're ordering, then why should the test be approved?"
How to avoid denial letters and educate patients on prior authorization
eviCore often uses peer-to-peer conversations between the ordering physician and one of our medical directors when a case has been denied. This doesn't require an appeal, per se, but rather an exchange of clinical information and a collegial discussion that can occur without the "red tape" of an appeal. This frequently results in a better decision about whether to do a certain test or procedure, and in some cases can help a patient get treatment before the denial letter is delivered, or even prevent the denial letter from being delivered at all. You can read more about the benefits of peer-to-peer conversations here.
Another helpful way to educate patients is to offer a printout in doctors' offices explaining that certain health plans might require that a requested test or procedure undergo prior authorization, which includes a review process. The printout can explain that, occasionally, a physician's order will not be approved (see the list above for common reasons why this is the case), but that there is an appeal process, and the doctor's office can usually help the patient appeal and/or find an alternative to the test or procedure.
When patients understand a little bit better why their doctor's request has been denied, and what they can do about it, prior authorization denial letters tend to be a lot less painful.