Prior Authorization for Advanced Imaging(MRI, CT,PET)

[tlburnsrnbsn]

For all nurses and staff who work in an MD office, do you have difficulty with the prior authorization process for MRI, CT, PET scans? Is it a hassle? Why? I want to know if there is a market for this type of training. Let me know what you think.

[Thornbird]

It really depends on what insurer, in my experience.

[tlburnsrnbsn]

Thanks for your comment. Specifically, the insurance companies that require prior authorization for any type of advanced imaging. There are insurance companies out there that do not require prior auth or it is a simple notification process. It is the companies that require prior auth for any advanced imaging that may be causing you the most heartburn for which I am wanting feedback.

[Halinja, BSN, RN]

Not sure this is really what you're asking but BCBS of Alabama pre-authorized my breast MRI (BAAAD family hx of breast cx) and then when the MRI showed no cancer first denied it as a pre-existing condition, then when it was pointed out there was no cancer, therefore not a pre-existing, denied it because it was medically un-necessary (because they didn't find anything???). It took seven months and tons of effort on the part of the doctor's office, the doctor herself, and me to finally get them to pay the bill.

[tlburnsrnbsn]

So sorry you had such a horrible time with your MRI. The information for my purposes begins with the initial process. I am searching for information from MD office staff regarding difficulties obtaining the initial prior authorization. Knowing correct CPT codes, studies requested, providing clinical, etc.

[VSBlonde]

I worked for 7 years as an imaging tech and now I'm working as a referrals coordinator for a multi-physican office while I'm in school. Several of the BC websites list the test codes along with criteria they deem necessary for the patient to present with in order for the test to be approved. I have found that it's very easy to get a CT IVP pre-certed for microscopic hematuria, but I had one denied twice for an MRA of the Abdomen to r/o ischemic colitis in a woman where the inferior mesenteric artery could not be indentified and she had lost 80 lbs in the 3 months. It was denied because she didn't have a documented fear of food...

I have a book that was put together for us by one of the hospitals that helps out everything together so that hopefully we can get the pre-cert the first time. Not all BCBS policies have to have pre-certs, I don't think UHC needs precerts yet, and Aetna hasn't given me much issues yet.

If I'm in a hurry, I don't always look up the CPT code and I just tell them the exam I want & they look it up for me. It makes the process a lot easier if your physicians are good at documenting stuff.

[carolinapooh, BSN, RN]

Thanks for your comment. Specifically, the insurance companies that require prior authorization for any type of advanced imaging. There are insurance companies out there that do not require prior auth or it is a simple notification process. It is the companies that require prior auth for any advanced imaging that may be causing you the most heartburn for which I am wanting feedback.

It's not just the company, it's also the level and type of coverage the patient has. Companies like Blue Cross/Blue Shield actually administer HUNDREDS of different kinds of policies, and not all of them require the same parameters.

When I worked in clinical research, the only thing we needed preauthorization for was major invasive surgery, like bypasses and organ transplants. Really. Now I work for a teaching hospital, pay twice as much for my insurance, and need preauth for everything.

BOTH policies are BCBS.

[VSBlonde]

It's really trial by error with each person's policy and having good information available. Sometimes denials are also based on the physician ordering the wrong exam, ie CT Brain for a HA, when it should be a MRI Brain. Given my background in imaging, my physicians trust me in my decision if an exam should be changed or ordered with/without contrast.

[tlburnsrnbsn]

Thanks so much for your feedback. With the background you have, your office is very lucky to have your expertise. And yes, it is the clinical provided, ordering the correct study and using the correct cpt code that make all the difference.

[tlburnsrnbsn]

Clarification: What I meant was, in my particular field, which is Prior Authorization for Advanced Imaging, I have found over the past 5 yrs, a definite lack of training for non-medical staff performing prior authorization.

For more information click here: www.rosewoodconsulting.biz and http://priorauthorizationtraining.blogspot.com

[xoemmylouox, ASN, RN]

I work in an md office. My job is to handle referrals and authorizations. I find that each company is different, as well as each plan. You will learn which require just a physician referral, and which require an actual authorization. I will warn you ins. policies always give themselves an out. They will say things like "even if authorized it will only be paid for if medically needed". Always check and make sure doctors in network. That can change often. Good luck!