Long post warning
This all depends on the patient’s insurance, your personal understanding of insurances’ procedure criteria, and your Pre Cert dept’s understanding (whether this is a separate dept or just your family member).
Hospital based practice. When I first joined, we would schedule ALL procedures (even TPIs) 15 business days out. This ends up being 3+ weeks out. I thought this was insane. So I became the “insurance guy” for our group and built a relationship with all the pre cert depts/staff. Also presented the necessary info to all the MDs. This changed everything. Now when we schedule procedures, I or scheduler will email the info directly to the Pre Cert staff and they work on it ASAP. Majority of procedures are auto approved/authorized ASAP. And we know they will get approved bc the note is strong. We schedule first and get auth later.
This issue really depends on your documentation. It must be bulletproof. Appropriate pain score, history/physical/diagnosis which supports the medical necessity of the procedure, imaging, and documented failure of conservative mgmt. If the note is crap (“proceed with epidural”), then the auth will go into clinical review which can take 2-3 weeks. Then you have to answer messages/emails, create addendums, do P2Ps… F that.
Every insurance is different. Some you enter a diagnosis, answer a few questions and can get an instant auto approval. Others require clinical/PT notes and have an authorization window. Some are NPR. No pre cert required. Can schedule/proceed asap. For the pt, there is no guarantee of payment by insurance. I have seen this apply to procedures, including lumbar MB RFA and even genicular RFA.
I have personally performed the auth process and if the documentation is appropriate, then the procedure typically gets auto approved on the spot.. i.e. takes 15 minutes, not 15 business days. In other cases, auth can take up to 2-7 days, even up to 15 days for strict ones like Medicaid or similar plans. Over time, I surmised that these depts “required 15 business days,” as they applied the most strict insurance review times to all pts. In the hospital, staff are probably lazy and not really incentivized to crank through procedure authorizations.
All plans are different. The marketplace plans here only require one MBB with 70% relief to proceed to RFA rather than the traditional MBB x2 with 80% relief. Most plans seem to mimic Medicare A&B.
Some procedures have a treatment time frame and others don’t. The ones that don’t, you can move them up earlier in the schedule.
Generally speaking…
-all payors — major joint, TPI, ESIs often can be scheduled asap.
-Medicare most procedures can be scheduled asap EXCEPT MBB/RFA. More recently, these require at least 5 days for approval once the necessary info has been submitted.
-I separate all MBB #1 and #2 by 14 days. For everyone.
-MBB/RFA generally has become more strict
-Medicare ESIs can be scheduled asap
-obviously SCS takes time for approval
As annoying as it is, you should be aware of the patient’s insurance so your note addresses that specific insurance’s requirements for the procedure’s medical necessity.
Last tip.. if you want to learn the exact criteria,
Google “CMS LCD xxx” this can be facet, epidural, SIJ, TPI, whatever. On the left, “Coverage Guidance”. Memorize this entire section or make a smart phrase. For commercial plans you can often google this as well.
So now we schedule patients in the first available slot. Get to know your Pre Cert dept/staff. Buy them tacos. Show them the way.
