Top 5 Issues to Avoid – Insider Tips from a Payer Expert

Introduction

Prior authorizations are meant to ensure safe, cost-effective care for patients. However, in practice, prior authorization can create roadblocks for health care providers and patients, often caused by delays and the time it takes provider offices to manage the prior authorization process. A 2024 study found that physician offices are spending over 13-hours per week managing prior authorizations. Of the 1000 physicians surveyed, 93% reported care delays, and 82% report that prior authorization can sometimes lead to treatment abandonment (AMA, 2024).

As someone who’s worked behind the scenes on the health insurance side of prior authorization and utilization management, I’ve seen firsthand how common, but preventable, issues can delay the prior authorization review process. In this article, we’ll break down the top-5 issues health plans and clinical reviewers see most often, and how small changes on the provider side can lead to faster prior authorization determinations, fewer denials and, most importantly, better patient outcomes.

Errors and Omissions - CPT, HCPCS and Dx Codes, Oh My!

Based on my personal experience, missing coding information and errors account for one of the top reasons why prior authorization requests are delayed. Insurance coverage policies, billing and provider reimbursement are tied to how a request is coded. If coding is inaccurate or incomplete, it causes a ripple effect in the prior authorization review and claims processes.

Common examples of coding errors include:

Missing primary or secondary diagnosis codes – Diagnosis codes ensure the reviewing clinician understands why a particular treat or service is being requested. Without this clarity, it can be difficult for the clinician to render a timely decision.

Outdated or incorrect CPT/HCPCS/Drug (J-Codes) codes – Outdated or incorrect coding can cause issues in the prior authorization review process. Examples include submitting prior authorization requests with temporary codes, although permanent codes have been assigned, or with codes that have been retired and/or replaced.

Coupled together, these errors can cause unnecessary treatment delays or denials. For example, submitting a prior authorization request for iron deficiency anemia, when the actual diagnosis is chemo-induced anemia, can trigger the wrong coverage and clinical policies. One diagnosis and treatment type may require prior authorization and step therapy, while the other might not.

Also important to note – health plans will not be able to assign diagnosis or treatment codes on behalf of the provider. Therefore, requests with missing or inaccurate coding information can trigger multiple phone calls to the provider office, the request might be returned as incomplete, or denied altogether. Additionally, this will not only affect the prior authorization process, but downstream claim and reimbursement processes. If the codes submitted through the claims process do not match an authorization, the claim can be denied.

Tip: Accurate and up-to-date coding is critical to ensuring there are no delays in the prior authorization process. Coding should be completed in the patient’s profile prior to submitting a prior authorization request. However, creating an internal cheat sheet with the most referenced codes, and key team members to reach out to for assistance, can be a beneficial resource for provider office staff.

Clinical Documentation – Mastering Prior Authorization Requirements

Another common cause of prior authorization delays are missing, or incomplete, clinical documentation. At minimum, the last office visit and a clear treatment plan should be submitted with each request. This standard information can help establish medical necessity and provides clarity on the patient’s medical history for the health plans clinical review teams.

Health plans reference clinical policy when reviewing prior authorization requests. These policies provide clear guidance on what is needed; depending on the treatment or service being requested, information beyond the office note and treatment plan might be required. For example, requests for chemo-induced neutropenia will require recent blood work with white blood cell counts within the past 30-days. In some cases, lab or imaging results completed within the past 30-90 days might be acceptable; however, this varies by health plan and clinical policy.

It’s important to note that if lab work, scans or biopsies have not been completed but are scheduled, you can include that information in the office note or treatment plan. Health plan reviewing clinicians can use their clinical judgment to approve the request on a shorter timeframe so that patient care isn’t negatively impacted. This will allow the patient to continue treatment uninterrupted while waiting for key clinical information to be collected at a later time.

Tip: Always check the health plans clinical policies for specific treatment or service. Creating an internal checklist of clinical documentation requirements by treatment type or category can help ensure key clinical information is submitted with each prior authorization request. This will reduce the back and forth communication between provider offices and health plans, speeding up the prior authorization review process.

Outdated or Missing Connections – Full Contact Information Matters

Missing provider information, like phone and fax numbers, NPI and TIN, can cause unnecessary delays in the prior authorization process. Health plan representatives may need to reach you to confirm patient or prior authorization request details (like confirming diagnosis and treatment information), or there may be follow-up questions concerning the patient’s medical history. Not having a clear point of contact, along with their contact information, can result in delays or denials.

Incorrect, or missing, NPI/TIN can cause issues tied to managed care contracting. For example, if the submitted NPI/TIN does not match the health plans contracted provider roster, this can trigger out of network messaging, out of network denials, or can cause provider reimbursement issues during the downstream claims submission process. Additional, and unnecessary, verification steps conducted by the health plans administrative teams to confirm provider information can delay the clinical review process.

Tip: To avoid prior authorization delays, it is important to always double check NPI and TIN to confirm:

• they are accurate and associated with your office
• they match credentialing and contracting information listed on file with the health plan
• they accurately reflect where the patient will receive the requested treatment or service

Additionally, a clear point of contact who can respond quickly to follow-up questions should be listed on the request. Phone and fax numbers should be accurate to ensure that communication from the health plan is sent to the right person. While these issues might seem minor, remaining diligent to ensure proper information can keep the prior authorization review process moving without hiccups.

Non-Covered and Exhausted Benefits - Avoiding Surprises in Prior Authorization

Submitting prior authorization requests for treatment or services that are not covered under the patients (or health plans) benefit, or benefits that have already been exhausted, is an avoidable error that causes delays in the prior authorization review process. This simple oversight often leads to unnecessary back and forth communication with the health plans and delays in getting the patient the treatment they need.

Prior to submitting a request for prior authorization, verifying the patients benefits and the health plans coverage policies is critical. There are services that might be excluded from certain plan types, only covered under specific diagnoses or clinical situations, or may require submission through a specific benefit type (for example, a drug might be excluded from the medical benefit and requires submission through the pharmacy benefit). Additionally, depending on the service or treatment type, the patient may have benefit limitations that only cover a specified number of visits or injections per plan year.

Despite challenges you might face with non-covered or exhausted benefits, there is no need to panic. In some cases, it might be beneficial to receive a denial. Denials can unlock additional sources of funding options for the patient such as patient assistance programs via the drug manufacturer, patient assistance foundations, or even the health system financial services department. The end goal is to ensure access to treatments and services with minimal financial impact to the patient.

Tip: Completing a benefits check prior to kicking off the prior authorization process can save health care providers time, avoid frustration, and can help provider office staff pivot quickly if a non-covered benefit situation arises. Sometimes a denial cannot be avoided; in this case, securing patient support is viable through other means, ensuring the member has access to the treatment and services they need.

Provider Portal Usage: Making the Most of Your Provider Portal – The Key to Faster PA Processing

Many health plan provider portals have implemented tools that can streamline the prior authorization process. Provider offices who aren’t using these portals to their full potential are missing out on key features that address the issues we’ve covered in this article. Incorrect codes, missing or incorrect contact information, and non-covered services can be flagged or avoided when using the provider portal.

Most portals offer features like auto-filled fields for NPI/TIN, member demographic details, and point of contact information like phone and fax numbers. These features reduce, and sometimes eliminate, the data entry errors that health plans see so often when processing prior authorization requests. Additionally, prior authorization requirements, health plan coverage policies, and benefit limitations can be checked during the submission process, reducing the chance of submitting a request for treatment or services that are fully excluded or over the allowed amount.

Some portals utilize built-in coding validation tools that flag outdated or mismatched codes. And as health plans remain dedicated to adopting automation for parts of the prior authorization review process, some requests may qualify for auto-approval review. This means that providers receive an instant approval that can be downloaded and saved as a PDF, or printed immediately, allowing provider office staff to attach the approval to the patients file. Auto-approval allows provider office staff to quickly move on to the next steps in the process to include scheduling, medication ordering, and/or coordinating additional services without delays.

Other valuable features within some provider portals include the ability to upload relevant clinical documentation, follow the prior authorization status in real time, and being able to communicate directly with the health plans prior authorization administrative staff, which saves provider offices from sending and receiving multiple faxes and phone calls. Utilizing the provider portal reduces the administrative burden for provider offices who use it on a consistent basis. Not using it might cost provider offices money that can be reinvested into staff training or workflow process improvement.

Tip: View the health plan provider portal as a valuable resource tool to help provider offices improve accuracy and increase efficiency during the prior authorization process, resulting in faster determinations and better patient outcomes. Providers can reach out to their assigned provider relations representative to find out how to register and begin using the portal today!

Conclusion

As mentioned at the top of this article, health care providers are spending over 13-hours each week on prior authorization; the majority of these delays are directly impacting patient care and access to the treatment and services they need. The issues causing these delays are completely preventable and provider offices can address these roadblocks with a few simple improvements to their submission process. Submitting relevant clinical documentation, ensuring accurate coding, including relevant contact information, checking and verifying benefits early in the process, and utilizing the health plans provider portal can reduce (or eliminate) back and forth communication, reduce denials and get faster prior authorization determinations.

The issues we’ve reviewed today are opportunities to reduce provider office staff burnout, reduce delays, improve patient outcomes and keep patient care moving. If you’re facing repeated roadblocks and hurdles with the prior authorization process, it might be beneficial to review your process to see if one or more of these issues are the root cause.

What challenges are you seeing within your practice when it comes to the prior authorization process? Are there parts of the process that do not work for your team, or that cause significant frustration? A PACS certified prior authorization specialist can pinpoint where the issues might lie, and help your practice avoid these common issues.

Author Bio

Chrystina Gonzalez is PACS certified and has spent over 10 years in managed care, specializing in prior authorization, appeals, and utilization management strategy. She has worked closely with both payers and health care providers, giving her a 360-degree view of the barriers patients and providers face in accessing treatment. Coming from the payer side, Chrystina understands exactly what goes on behind the scenes with prior authorizations, denials, clinical and coverage policies. This insight helps her to anticipate issues in order to proactively support patients and health care providers in navigating access challenges.

Chrystina Gonzalez, MBA, CLSSGB, PACS

Prior Authorization & Utilization Management Expert

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References

1. American Medical Association. 2024 AMA prior authorization physician survey. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf