Predetermination vs Prior Authorization

Predetermination vs Prior Authorization

Utilization management (UM) reviews are a component of the value-based care approach. They aim to determine if the care provided to patients is appropriate, efficient, and linked to improved patient outcomes. The UM processes of insurance companies include prior authorization, predetermination and post-service review. Prior authorization or “pre-auth” and predetermination occur before the clinical event or provision of the service. Insurance authorization companies help physician practices effectively navigate the challenges associated with these complex and time-consuming medical insurance coverage requirements.

Let’s take a look at the specifics of preauthorization and predetermination and the differences between these two types of reviews.

What is Preauthorization?

Prior authorization, also known as preauthorization, prior approval, or precertification,is a process that insurance companies use to determine whether a patient is eligible to receive certain procedures, medications, or tests, except in an emergency. Prior authorization is done to determine whether a service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary. Types of treatments and medications that may require prior auth are:

  • Expensive medications and treatments
  • Drug interactions or combinations that can be unsafe
  • Relatively cheap available alternatives
  • Drugs and medical treatments specially prescribed for unique health issues
  • Drugs that are often misused or abused
  • Medical procedures such as surgeries, transplants, imaging and other tests
  • Behavioral services such as mental health, psychological testing and psychiatric care.
  • Drugs often used for cosmetic purposes

The insurer will review the requested service or drug to see if it meets certain criteria:

  • Is medically necessary
  • Is appropriate and follows up-to-date recommendations for the medical problem
  • Is the most economical treatment option available for the patient’s condition
  • Will be delivered in an appropriate setting
  • Is not being duplicated (for e.g., two CT scans ordered for the patient by different physicians)
  • If the ongoing or recurrent service (such as physical therapy) is actually helping the patient
  • Is covered under the patient’s health plan

Health plans have their own rules as to what services need prior authorization. Typically, high-cost medications and expensive treatments require pre-authorization. Outpatient procedures, certain invasive procedures, durable medical equipment (DME) and CT, MRI and PET scans are examples of services that may require pre-certification. Without this prior approval, the health plan may not pay for the treatment, and the patient or the in-network ordering or servicing provider would have to bear the cost.

Usually, requesting prior authorization is the responsibility of the provider if the patient is being treated by a physician in the plan’s network. Some plans require the patient to request prior authorization for services.

Insurance authorization companies manage prior authorizations by telephone or using web portals. Prior authorization requires information such as patient demographics, insurance information, and physician information as well as clinical review. Within 5-10 business days of receiving the prior authorization request, the insurance company will either:

  • Approve or deny the request
  • Ask for additional information
  • Recommend trying a less costly but equally effective alternative, before the original request is approved

Though the goal is to ensure that health care is cost-effective, safe, necessary, and appropriate for each patient, the use of prior authorization can pose a challenge to care delivery. For example, if a medication prescribed for a patient with an ongoing chronic condition requires prior approval, it can delay treatment and slow the patient’s progress.

In 2021, FierceHealthCare published a report on how prior authorizations can disrupt medically necessary care. Cataracts disrupt everyday activities, make it harder to drive or work safely, and increase the risk of falls and accidents. The report explained how a leading insurance company’s new prior authorization requirement deprived patients of getting cataract surgery. The prior authorization requirement covered all cataract surgeries, across all of its plans and regardless of patient health status. According to the report, within the first month that the policy went into effect, the cataract surgeries of thousands of patients were canceled. The report also pointed out that even with as the pandemic continues, the number of medical services requiring prior authorization is increasing, and getting worse across specialties such as oncology, rheumatology, and psychiatry.

What is Predetermination?

A predetermination is a formal review of a patient’s requested medical care compared to their insurance’s medical and reimbursement policies (MGMA). The aim is to determine if the intended care meets medical necessity requirements.

Insurance companies do not always require predeterminations, but they use for various reasons:

  • Predeterminations are required for the determination of medical necessity before rendering services (in addition to checking eligibility and benefits).
  • Predeterminations may be used if the provider is not sure about coverage for a service.
  • Predetermination confirms the amount that the insurer will reimburse for the service
  • If a medical procedure, treatment or test is not covered, the in-network ordering or servicing provider or the member will be responsible for paying the bill.

All patient clinical information to support the need for the intended procedure will be submitted by the provider’s office and the insurance company will be requested to review the patient’s conditions based on policy requirements.

Services that are not considered life threatening do not need predeterminations. Most services that require a formal predetermination include experimental, investigational, or cosmetic services. Examples of procedures for which a predetermination review is recommended:

  • Abdominoplasty
  • Bariatric Surgery
  • Blepharoplasty /
  • Ptosis Repair
  • Botox
  • Breast Reduction
  • dental surgery
  • liposuction
  • PET scans
  • orthotics
  • transplants
  • Varicose Vein Procedures
  • Sacroiliac (SI) Joint Injections

Predeterminations are not required for services and drugs that require prior authorization. Most dental insurance companies recommend submitting a dental predetermination for treatment plans over $300.

Predeterminations are extensive reviews and usually come with a turnaround time of 30 to 45 days, and even 60 days in some cases. Patients and providers need to be aware of the importance of waiting for these medical reviews to be approved for coverage.

Predeterminations inform patients about their insurance. Also, it can delay treatment for simpler dental restorative procedures – for some plans sending in a pre-determination is required because they follow a different fee schedule than what you expected. However, while the aim of filing predeterminations is get a better idea of how much the procedure costs and who (the insurer and patient) will be paying for what, the numbers may be inaccurate. Additionally, it does not guarantee approval from insurance companies to pay the claim. Insurance verification is the best way for practices to get a cost estimate by verifying information regarding the patient’s insurance coverage, payable benefits, co-pays and co-insurance, details on the plan related to coverage, date of coverage, type of plan, exclusions, deductibles, and other key details about the insurance plan.

Difference between Preauthorization and Predetermination

While both preauthorization and predetermination are UM processes used by insurance companies to determine whether a service is covered under the health plan and its medical necessity, they are different.


  • Allows providers to get approval from the insurance company before services are rendered
  • Is required for some patients/services/drugs before services are rendered to confirm medical necessity as defined by the patient’s health benefit plan
  • Does not guarantee reimbursement
  • Failing to get preauthorization could result the responsibility for payment falling on the patient or provider
  • Can take up to 30 days to get approved


  • Provides a confirmation that the patient is a covered member of the insurance plan and that the treatment plan for the patient is a covered benefit
  • Is optional, but recommended to understand coverage for services considered experimental or investigational when performed for other purposes
  • Is not needed for services and drugs on the prior authorization list or for services that are not considered life threatening
  • Can take up to 30 to 60 days for approval
  • Confirms the portion of the fees that will be reimbursed

Benefits of Preauthorization and Predetermination

Insurance companies use preauthorization and predetermination to ensure that patients receive only treatments and medications that are necessary. They will compare recommended treatments with industry practices and approve those treatments that are required for the patient’s health. If a more affordable, appropriate treatment is available, they will deny the claim. The benefits of preauthorization include:

  • Promotes safety
  • Supports cost minimization
  • Prevents drug misuse
  • Helps patients avoid unnecessary medical procedures

How an Insurance Authorization Company can Help Physician Practices

Understanding processes and how to submit requests to meet the requirements of insurance companies is essential for physician practices to avoid lost revenue and help patients get the care they need promptly and also avoid negative financial impacts.

Both prior authorizations and predeterminations are time-consuming, tedious processes. Partnering with an insurance authorization company that has professionals with expertise in managing preauth and predetermination processes can help practices:

  • Reduce the risk of the insurer denying payment for the treatments
  • Submit predetermination requests for complex, costly procedures to the insurer at the earliest time possible and provide prompt patient care
  • Avoid unnecessary costs to the patient
  • Help practices improve revenue and get quicker reimbursement

Insurance verification specialists will verify patient benefits before services are provided to ensure accurate claim submission. They would also be up to date with the rules and requirements of different insurance companies in terms of what requires preauthorization. An expert can help practices compile a list of all the procedures that require prior auth from which payers and under what conditions. Once a request has been submitted, they will perform regular follow up calls, checking on the status of the request until the answer has been obtained. With expert support for managing prior authorizations and predeterminations, physicians can save time and money focus on their patients.

What is the Difference between Insurance Verification and Insurance Authorization?

What is the Difference between Insurance Verification and Insurance Authorization?

Revenue cycle management (RCM) is the administration of financial transactions that result from the medical encounters between a patient and a provider, facility, and/or supplier, according to the Healthcare Business Management Association (HBMA). RCM involves several processes from the time a patient schedules an appointment to claim submission and payment collection. Insurance verification and authorization are key processes performed in the initial phase of RCM or medical billing insurance claims process. Though both aim at preventing claim rejection and delays, insurance verification and prior authorization are distinct and different.

What is Insurance Verification?

The life cycle of a patient begins with appointment scheduling and registration where demographic and insurance information are collected. This sets the stage for insurance verification – the process of checking the patient’s health payer coverage and benefits prior to the encounter. The goal is to confirm:

  • If the patient has active insurance coverage
  • What procedures/services are and are not covered
  • How much of each procedure the insurer will cover and the patient’s financial obligation

The following information is collected when a patient calls to schedule an appointment:

  • Patient’s name and date of birth;
  • Name of the insurance provider
  • Name of the primary insurance plan holder and their relationship to the patient;
  • Patient’s policy number and group ID number (if applicable); and
  • Insurance company’s phone number and address

A reliable insurance verification service provider will make sure that all the required details about insurance eligibility and benefits are collected before the patient visit, which includes:

  • Type of plan and coverage details
  • Calendar year/ policy year
  • Effective date
  • Plan annual maximum
  • Plan deductible
  • Primary and secondary insurance
  • Per code coverage, if available
  • Copays and deductibles
  • DME coverage
  • Plan exclusions
  • Referral and pre-authorization requirements
  • Out of network benefits

Insurance verification specialists will get a full breakdown of patients’ insurance coverage and benefits by visiting payer web portals or calling the insurance carrier with the information collected from the patient during the initial phone call.

Proactive patient eligibility verification is crucial for a successful claim submission in medical billing:

  • Improves the patient experience: Verifying the patient’s insurance before the office encounter and communicating to them as to what their plan covers and doesn’t cover will ensure transparency. Patients will know about the costs of their care and can better prepare to pay their bills. With transparency throughout the medical billing process, patients will not face any costly surprises.
  • Reduces claim denials: If the patient’s information is outdated and the provider uses that to submit a claim, it would result in an instant payment denial. Verifying patient eligibility upfront will ensure that claims are submitted with current and accurate data and prompt payment. Insurance verification services minimize claim denials and saves time and money that would go into reworking claims.
  • Maximizes cash flow: Proper insurance verification will ensure that claims are submitted with up-to-date information. Clean claims will be approved faster and speed up the medical billing cycle. Reduced denials and a larger number of clean claims will increase practice cash flow.

What is Insurance Authorization?

Insurance authorization or prior authorization is a “health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage” (American Medical Association). Prior authorization is also referred to as precertification, pre-authorization, prior approval, and predetermination. Insurance companies use the prior authorization process to determine if a prescribed medical treatments, drugs, or medical equipment will be covered in full or in part.

The insurance authorization process begins when a service prescribed by a patient’s physician is not covered by their health insurance plan. The physician’s office has to communicate with the insurance company and complete a prior authorization form along with documentation supporting the medical necessity of the specific procedure, test, medication, or device. Prior authorization is a time-consuming process that can delay patient access to care.

Insurance Verification vs. Insurance Authorization

The differences between insurance verification and insurance authorization are as follows:

  • Unlike insurance verification which is performed before the patient encounter, the prior authorization process begins when a procedure, test, medication or device that the physician prescribes for a patient requires preapproval from the insurer.
  • Insurance verification is related to the process of creating and filing medical claims and obtaining payment for patient services, while prior authorization is about obtaining prior authorization for services.
  • For a smooth preauthorization process, medical billing personnel need to be knowledgeable about the CPT code for the services for which approval is requested. Insurance verification focuses on coverage status, active/inactive status and eligibility status.

Both insurance verification and authorization are time consuming processes that can lead to denials. That’s why they are best handled by experts. Outsourcing these tasks to an experienced insurance verification company can go a long way toward saving time, preventing denials and delays, optimizing reimbursement, and improving patient care and satisfaction.

Why is Insurance Preauthorizations a Major Challenge for Gastroenterology Practices

Why is Insurance Preauthorizations a Major Challenge for Gastroenterology Practices

Getting prior authorizations is a complex, time consuming, and frustrating task for physicians and their staff. Insurance verification and insurance authorization have a key role in revenue cycle management. That’s why busy practices prefer to rely on insurance verification and pre-authorization services provided by experts to get the job done.

Prior authorization (PA), prior approval or precertification is used by payers to determine if a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. While the prior auth process was intended to maintain care standards, improve safety and regulate costs, today, it is become a cumbersome process that is difficult to navigate.

According to an MDedge report, insurance companies are including more and more CPT® codes for services and procedures included in their prior authorization programs. The report highlights the problems faced by gastroenterology practices in managing prior authorizations which have been extended to multiple services and procedures by insurers. Gastroenterology practices require preauthorization for office visits and various procedures. Common CPT codes requiring pre-authorization include:

99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making

99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making

43239, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple

43459 Stool for Electron Microscopy

45380 Colonoscopy, flexible; with biopsy, single or multiple

45385 Colonoscopy with polypectomy

Leading insurance company Anthem has included the entire family of esophagogastroduodenoscopy (EGD) codes to its list of procedures requiring prior authorization in 10 states, says the MDedge report. The codes in this list are:

43233 Esophagogastroduodenoscopy, flexible transoral; diagnostic, with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)

43235 Esophagogastroduodenoscopy, flexible transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

43236 Esophagogastroduodenoscopy, flexible transoral; with directed submucosal injection(s), any substance [other than injections related to gastroesophageal reflux or dysphagia]

43239 Esophagogastroduodenoscopy, flexible transoral; with biopsy, single or multiple

43241 Esophagogastroduodenoscopy, flexible transoral; with insertion of intraluminal tube or catheter

43243 Esophagogastroduodenoscopy, flexible transoral; with injection sclerosis of esophageal/gastric varices

43244 Esophagogastroduodenoscopy, flexible transoral; with band ligation of esophageal/gastric varices

43245 Esophagogastroduodenoscopy, flexible transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)

43246 Esophagogastroduodenoscopy, flexible transoral; with directed placement of percutaneous gastrostomy tube

43247 Esophagogastroduodenoscopy, flexible transoral; with removal of foreign body(s)

43248 Esophagogastroduodenoscopy, flexible transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire

43249 Esophagogastroduodenoscopy, flexible transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)

43250 Esophagogastroduodenoscopy, flexible transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps

43251 Esophagogastroduodenoscopy, flexible transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

43254 Esophagogastroduodenoscopy, flexible transoral; with endoscopic mucosal resection

43255 Esophagogastroduodenoscopy, flexible transoral; with control of bleeding, any method

43266 Esophagogastroduodenoscopy, flexible transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

43270 Esophagogastroduodenoscopy, flexible transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) [other than ablation related to Barrett’s esophagus]

According to MDEdge, gastroenterologists were forced to cancel planned procedures because the prior authorization process took weeks instead of days. Physicians also reported that the cumbersome preauthorization process and medication delays led to patients having flares of inflammatory bowel disease. The American Gastroenterological Association (AGA) is working to find legislative solutions to ensure that Medicare Advantage (MA) plans increase transparency, restructure the prior authorization process, and minimize the impact on Medicare beneficiaries.

In a 2018 survey by the American Medical Association (AMA), 91% of physicians said prior auths negatively impacts care. Eighty-six percent of physicians believe their PA burdens are high or extremely high. Problems identified:

  • Practices had to complete an average of 31 prior authorizations per physician per week, which meant dedicating almost two business days to administrative tasks.
  • A third of physicians employed staff exclusively for processing prior authorizations.
  • 65% of providers wait more than one business day for a PA decision from the patient’s health plan – 26 percent will wait more than three business days, on average.
  • 75% of physicians said that extended waiting periods for treatment led to abandonment among patients
  • 28 percent of physicians said prior auth delays have led to a serious adverse event for a patient, such as a death, disability or permanent damage, hospitalization, or other life-threatening emergency.

Fierce Healthcare sums up it up: “Prior authorization typically requires staff to follow a laborious workflow that can be difficult to track to completion. Multiple data entries, payer rule discrepancies, inconsistent payer documentation requirements and changing government mandates hamper these processes. Prior authorizations can take an inordinate amount of time, which decreases productivity, wastes resources, can lead to treatment delays and may adversely affect patient outcomes”.

Verifying patient insurance benefits is also an important but challenging task that practices have to handle. Physician practices need to complete benefit verifications before the office visit. If insurance eligibility and benefits are not verified before services are provided, it can lead to claim denials and loss of reimbursement.

Outsourcing the insurance verification and prior authorization process can bring efficiency in managing these processes, and save time and money. It will help patients get access to medications and treatments faster. Companies offering insurance verification and authorization services have experts on the job. They are knowledgeable about the process and how it works and can complete the pre-auth process, keep track and follow-up if required, and appeal denials. These services are budget-friendly and practices can avoid the need to hire separate staff to manage the task in-house. Relieved from the administrative burden, of managing prior authorizations, physicians can focus on their core tasks.

Frequently Asked Questions about Pharmacy Prior Authorization

Frequently Asked Questions about Pharmacy Prior Authorization

A December 2017 study from the American Medical Association reported that 86 percent of physicians said that prior authorizations have increased during the prior five years, with 51 percent saying that they have increased significantly. The PA process for approval of high-cost specialty medications is burdensome, and costs pharmacies and physicians’ practices a lot in terms of time and money. Pharmacy prior authorization distracts from patient care, can delay care and even cause patients to abandon treatment. Outsourced insurance authorization services are a practical option for physicians to standardize in-office processes for handling prior authorizations, obtain prior approval quickly, and get paid for services provided.

Here are answers to frequently asked questions about pharmacy prior authorizations:

  • What is pharmacy prior authorization?
    Prior authorization (PA) is a requirement that healthcare providers obtain advance approval from a health plan before a specific procedure, service, device, supply or medication is delivered to the patient to qualify for payment coverage. Pharmacy prior authorization is the requirement for approval from the patient’s health plan for a prescription drug.
  • Why do health insurance companies require pharmacy prior authorization?
    Health insurance companies use a PA as a means to ensure that a drug prescribed is truly medically necessary and appropriate for the patient’s situation. PA is a method for minimizing costs by ensuring that the prescribed drug is the most economical treatment option available to treat the condition. For example, if the physician prescribes an expensive drug, the insurance company may authorize it only if the physician can show that it is a better option than a less expensive medication for the condition.
  • What types of drugs require PA?
    According to Consumer Affairs, the following kinds of drugs are subject to PA:

    • Brand name medicines that are available in a generic form
    • Expensive medicines, such as those needed for psoriasis or rheumatoid arthritis
    • Drugs used for cosmetic reasons such as medications used to treat facial wrinkling
    • Drugs prescribed to treat a non-life threatening medical condition
    • Drugs not usually covered by the insurance company, but said to be medically necessary by the prescriber
    • Drugs usually covered by the insurance company but are being used at doses higher than normal
  • Blue Cross Blue Shield requires prior authorization for those drugs:
    • that have dangerous side effects
    • are harmful when combined with other drugs
    • should be used only for certain health conditions
    • are often misused or abused
    • are prescribed when less expensive drugs might work better
  • What are the steps involved in the pharmacy prior authorization process?
    The physician prescribes a specific drug. If the prescription requires PA, the pharmacy will contact the physician who prescribed the medication and inform the provider that the insurance company requires a PA. At this stage, the patient can either opt to wait for coverage approval from the insurance company or pay for full cost of the prescription themselves. The physician will contact the insurance company and submit a formal authorization request according to the plan’s guidelines,along with the necessary forms. The insurance company may also require the patient to complete some paperwork or sign some forms. The insurance company will review the request and may either authorize the drug or refuse to cover it.
  • What are the common reasons why a patient’s prior auth request may not be approved?
    • The patient did not give the insurance company, physician, and pharmacy enough time to complete the needed steps, which can take several business days.
    • The insurance company denied the claim
    • The insurance information was outdated or the claim was sent to the wrong insurance company
    • The medication was not medically necessary
    • Supporting evidence was inadequate
    • The physician’s practice did not contact the insurance company
    • The wrong PA code was used to bill the medication
    • Payer rules changed
    • The practice does not have the capability to manage PAs
    • The physician did not meet payer guidelines

In some cases, the approval of the drug may be valid for a limited time such as one year or one month. In such cases, the authorization process must be restarted.

  • How long does prior authorization take?
    Obtaining a prior authorization is a time-consuming process for physicians and their staff. A 2010 American Medical Association (AMA) survey, found that physicians spend about 20 hours of a traditional work week on PA activities. The AMA also reported that more than 60% of physicians said they needed to wait at least one business day to complete prior authorizations, while 30% said they have had to wait three business days or longer to get a response on a prior authorization request. Further delays occur if coverage is denied and must be appealed. An appeal can take several days to process.
  • What can be done if a prior authorization is denied?
    If patients believe that their pharmacy PA was incorrectly denied, they can appeal the rejected claim. They would need to first contact the insurance company and ask why the claim was denied. If the insurance company indicates a billing error or missing information, patients can work with their physician to review the paperwork and fix any errors that caused the denial. They can also ask the physician to provide backup evidence or notes that could help prove that the prescription is medically necessary. The chances of success in resolving a prior authorization denial are higher when the physician ensures that all clinical information is included with the appeal, including any data that may have been missing from the initial request.

Prior authorization stands in the way of proper and timely patient care. In an AMA survey of 1,000 practicing physicians, nearly 90 percent of the physicians reported that the administrative burden related to PA requests has risen in the last five years, with most saying it has “increased significantly”. Led by the AMA, physicians, payers and other stakeholders are working to improve the prior authorization process.

Outsourcing the insurance authorization task is a reliable option to ease this burden. This brings us to the question – how do insurance authorization services work?

Insurance authorization companies have experienced personnel who act as an enabler between the physician’s practice and the payer. These experts have extensive experience in working with all government and private insurances. They will collect the patient information from the practice to obtain prior authorization for medications and services. Insurance authorization services cover the following:

  • Verifying patients’ benefit information before the office visit, which will ensure clean claim submission.
  • Contacting payers to obtain pre-authorization quickly
  • Ensuring that payer criteria are met before submitting the request
  • Submitting all necessary documentation with PA requests
  • Managing any follow-up, such as getting more information from the physician for the pre-authorization
  • Support for appealing denials

Insurance verification and authorization support is often a part of outsourced medical billing services.

Radiology Prior Authorizations – What Practices Should Know

Radiology Prior Authorizations – What Practices Should Know

Failure to obtain proper prior authorization is one of the key reasons for claim denials in many medical specialties and radiology is not an exception. Whether you are an imaging specialist or a referring physician, prior authorization from the insurer helps to ensure that patients can undergo the procedures they need in a timely manner. Radiology prior authorization services are now available so that radiology practices do not have to spend their time obtaining pre-authorizations and following up with clinical documentation.

Before rendering the service, the radiologist must verify that prior authorization was obtained. Payments are denied for procedures performed without the required authorization.

Radiology exams that may require pre-authorization include:

  • Bone Mineral Density exams ordered more frequently than every 23 months
  • CT scans (all diagnostic examinations)
  • MRI/MRA (all examinations)
  • Nuclear cardiology
  • PET scans
  • Stress echo cardiograms

The process for authorization must begin at the time of the patient’s registration for an appointment. The front office staff must gather as much information as possible about the patient’s condition and the reasons for the exam. All details are important, as it may be necessary for the radiology department or imaging center staff to contact the referring physician’s office. Also, the staff should verify that imaging orders are appropriate and complete. In some cases, it can be seen that the referring office will have obtained an authorization from the insurance company.

Accurate Codes as Crucial as Authorization

Along with prior approval, it is also important that specific procedure and diagnosis codes are reported in the claim for it to be processed correctly. CPT coding updates in radiology for 2019 has brought many new codes and deleted some. New codes that were added include:

    • 77046 MRI Breast, without contrast, unilateral (deleted code 77058)
    • 77047 MRI Breast, without contrast, bilateral (deleted code 77059)
    • 77048 MRI Breast, without and with contrast, unilateral (deleted code 77058)
    • 77049 MRI Breast, without and with contrast, bilateral (deleted code 77059)
    • 76978 Targeted dynamic microbubble sonographic contrast characterization (non-cardiac); initial lesion
    • 76979 (Add-on) Each additional lesion with separate injection
    • 76981 Elastography, parenchyma (e.g., organ)
    • 76982 Elastography; first target lesion
    • 76983 (Add-on) Each additional target lesion, not to be used more than two times per organ

ICD-10 codes related to imaging procedures include:

    • R93.421 Abnormal radiologic findings on diagnostic imaging of right kidney
    • R94.02 Abnormal brain scan
    • R94.11 Abnormal results of function studies of eye
    • Z12.3 Encounter for screening for malignant neoplasm of breast
    • Z12.4 Encounter for screening for malignant neoplasm of cervix

Once the authorization is obtained, your practice must verify that the approval matches the exam to be performed, including the date of service since authorizations can expire. In case of any delay in obtaining authorization, the appointment should be rescheduled to avoid denial. Appointment scheduling services should be perfect to avoid patient dissatisfaction and payment delays.

Any changes to the procedure actually ordered should also be communicated to the insurance company so that the procedure codes ultimately sent in on the claim form match the payer’s authorization records. Results of the authorization process should be monitored to make sure that the claims are paid as timely and accurately as possible.

To avoiding payment denials due to failure to obtain proper authorization, radiology practices can train their registration staff to gather as much detailed insurance information as possible from patients, make them aware of which procedures require prior authorizations and forward appointments for those procedures to the dedicated authorization staff, ask them to obtain or verify authorizations when they are required and reschedule patient appointments when needed, and advise them to notify the authorization staff of any changes that occur if the actual exam performed is different from the one authorized.

Authorization Guidelines from NIA

Based on the clinical guidelines from NIA (National Imaging Associates),

    • Only one authorization request is required for Abd/Pelvis CTA & Lower Extremity CTA, using CPT Code 75635 Abdominal Arteries CTA
    • For Abdomen/Pelvis MRA & Lower Extremity MRA Runoff Requests, two authorization requests are required – one Abd MRA, CPT code 74185 and one for Lower Extremity MRA, CPT code 73725
    • An authorization for MRI in addition to MRA is not required, as a request for MR Angiography includes standard MRI imaging
    • A single authorization for CPT codes 70486, 70487, 70488, or 76380 includes imaging of the entire maxillofacial area including face and sinuses. Multiple authorizations are not required.
    • A single authorization for CPT code 70540, 70542, or 70543 includes imaging of the Orbit, Face, Sinuses, and Neck. Multiple authorizations are not required.

As the pre-authorization process can be very time-consuming, requiring constant follow-up by the radiology office, it is more practical to outsource the task. Professional medical billing companies will be up to date with the changing insurance authorization requirements, when scheduling patients for radiology exams. Skilled Prior Authorization Coordinators in such companies will call insurance companies and get authorizations in the most efficient manner. Authorization specialists will verify that the documentation is complete and will then coordinate the authorization approval with the insurer.

Addressing the Challenges of Insurance Authorizations in Dermatology

Addressing the Challenges of Insurance Authorizations in Dermatology

One of the administrative challenges that physicians have to deal with is obtaining prior authorizations for prescriptions and testing. This has led to an increase in the demand for insurance authorization services in recent years. Prior authorization is major problem in the delivery of dermatology care. In May 2019, MDEdge reported on a study which found that prior authorizations for dermatology care at the University of Utah nearly doubled in the last two decades.

Prior authorization is a process which requires physicians to obtain prior approval before delivery of a specific treatment or service in order to qualify for payment. Health plans maintain that insurance authorizations protect patients by ensuring that the prescribed treatment is safe, medically necessary and appropriate. However, an American Medical Association (AMA) survey of 1000 practicing physicians showed that payers’ prior authorization requirements delay treatment, have a negative impact on clinical outcomes. and lead patients to abandon treatment.

Previously, health plans utilized prior authorization for newer, costly services and medications. However, in recent years, physicians report that most prior authorizations are for drugs and services that are neither new nor expensive.

 Insurance Authorizations a Major Roadblock in Dermatology

 The University of Utah study provided the following evidence of the increasing burden of prior auths in dermatology:

  • In September 2016, one prior authorization was required for every 15 patient visits (6.7%) over a 30-day period. In comparison, in September 2018, one prior authorization was required for every 9 patient visits (11.1%) over a 30-day period.
  • The number of clinic visits during September 2018 was 2.4% higher than in September 2016 (9,743 vs. 9,512), and the volume of prior authorizations increased by 73.8% (1,088 vs. 626).
  • In one case, 81% of the reimbursed cost for a patient visit was spent seeking a prior authorization.
  • The time and cost burden (on a per-visit basis) was the highest for prior auths for biologics.
  • Nonbiologic medications had the highest proportion of denials (25%).

A recent report in Practical Dermatology summed up the views of dermatologists on the prior authorization process:

  • The number and types of drugs needing prior authorization is increasing and constantly changing.
  • Health plans’ formularies are widely variable, and the associated processes have become more difficult.
  • Dermatologists often have no idea of the clinical rationale for insurance authorization or why a drug/service is denied.
  • A PA request may be denied even after provision of the requested documentation.
  • In some cases, the drug approved by the plan as a first-line therapy might be outdated, ineffective, or even unsafe for the patient.
  • Many plans continue to have inefficient and time-consuming prior auth processes and communications, leading to delays.
  • Dermatologists being required to prescribe on-formulary medications (for conditions such as psoriasis, atopic dermatitis, and acne) that are outdated, unsafe, ineffective, or medically inappropriate for the patient.
  • Lack of a proper process or designated contact person for discussing PA denials and/or lack of information provided to the dermatologist by a plan.
  • Problems in obtaining approval to use non-FDA indicated medications for pediatric patients.

It can happen that a drug that the physician prescribes is the one that would really work for a complex skin condition, but the insurance company may not cover it (

The insurance authorization process requires time and resources, and also impedes timely and efficient provision of care. In an AMA survey, more than 60% of physicians said they needed to wait at least one business day to complete prior authorizations, while 30% said they have had to wait three business days or longer.

Impact on Patients

Prior auths can be extremely frustrating for patients. The AMA cited dermatologist and health policy expert Jack Resneck Jr., MD as saying that, due to the rapidly changing requirements and the number of health-plan drug lists, physicians may not know which insurers will require PA for a given medication in a particular patient. As a result, the insurance authorization process often begins when a patient is told by the pharmacist that their medication requires further approval. He said that his patients faced long delays to receive their medication, which left their condition untreated. Consequently, patients had to make additional trips to the pharmacy.

Patients whose treatment requires prior auth often abandon their recommended course of treatment. Nearly 80% of the physicians in the AMA survey said that prior auth issues led patients sometimes, often or always to abandon the recommended test or treatment.

Strategies to Overcome Prior Authorization Hurdles

Both the AAD and the AMA are working towards improving the efficiency of the prior auth process. The American Academy of Dermatology (AAD) offers several tools, including templated prior auth letters, to address drugs commonly requiring PA. The AAD also provides resources to help dermatologists communicate with patients about why PAs occur and about possible treatment-access delays.

Experts recommend standardizing processes for handling prior authorizations. Physicians also need to collaborate with health plans to build a more efficient prior authorization process. They should communicate effectively with patients regarding prior authorizations. Physicians should explain to patients that coverage for some medications, tests, and referrals are dictated by the insurance. If prior auth is required, they should educate the patient on the process and the possibility that the authorization will take time and that there may a delay in care. They should also explain that coverage may be denied.

Having pre-authorizations handled by experts is a practical solution. Insurance authorization companies have trained staff skilled in CPT-ICD coding and well versed in the rules of medical necessity requirements and each payer’s requirements, including deadlines, documentation, etc. Experts can handle prior authorization for inpatient and outpatient surgeries, hospital admissions, diagnostic imaging and more. With their expertise in the field, insurance verification and authorization experts can help practices improve workflow, drive higher reimbursement, reduce denials, and improve patient satisfaction and retention.