Procedure prior authorization time?

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so55b

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When I see new patients or follow-ups, we usually schedule any procedures 3 weeks out so that my staff can work on prior authorization in between. Is it common for other pain clinics too? Of course, many patients are complaining about waiting time and it makes my schedule inefficient.
 
to long for ESIs, SIJ, joints. might take that long to get auth for facet procedures. makes more sense to schedule them when you have the auth rather than 3 weeks for everyone
 
Our schedules are now told to tell patients to not even expect a phone call to schedule for at least 2 weeks. 🤦🏻‍♂️
 
Oh yeah, that does not sound very unique to just a few pain clinics. It seems many places are starting to schedule procedures out a few weeks so that there will be time for prior authorization. But I do understand the annoyance with the wait times though wait time is really a big no-no for fixing the schedule. Perhaps there’s a more efficient way to organize or perhaps there’s a buffer so that you never find yourself with gaps?
 
Related, is anyone using AI for prior auths? our clinic spends so much time on letters and phone calls to the insurance company. I have seen reports that AI can improve this but wondering if anyone is doing it?
 
we get auth first then schedule as soon as auth is obtained.


i dont use AI but i have smartphrases that are in concordance with CMS guidelines and revised whenever there are changes (and i get the chance).
 
"So I'm not getting my injection today? My primary care doctor told me you would do it today. What am I going to do in the meantime, suffer?"

This happens multiple times per day, typically from patients who report back pain "since childhood".
 
"So I'm not getting my injection today? My primary care doctor told me you would do it today. What am I going to do in the meantime, suffer?"

This happens multiple times per day, typically from patients who report back pain "since childhood".
Sure, we can probably to it today or tomorrow but if we do it without insurance approval and they don't approve it after the fact, you'll just be on the hook for the full amount. My scheduler will give you the quote. Bye!
 
I would just offer them the affordable cash price if it was an insurance with difficult PA’s and they wanted it done quickly.
 
"So I'm not getting my injection today? My primary care doctor told me you would do it today. What am I going to do in the meantime, suffer?"

This happens multiple times per day, typically from patients who report back pain "since childhood".
"well you've been suffering this long havent you? If another week is too much. you can pay out of pocket and then settle the bill later with your insurance"
I would just offer them the affordable cash price if it was an insurance with difficult PA’s and they wanted it done quickly.
agreed.
 
My staff has a good gestalt on time to approval and we tentatively schedule almost everyone asap. If gets hung up push out and blame insurance. Empty spots on schedule fill fast
 
As others mentioned Medicare, others fast. Next day. Easier with in office suite than asc and I do procedures all day every day.

Own some bars. Make it easy to buy a drink. Same principle
 
"So I'm not getting my injection today? My primary care doctor told me you would do it today. What am I going to do in the meantime, suffer?"

This happens multiple times per day, typically from patients who report back pain "since childhood".
It all started when I fell out of a tree when I was six.

Me: you are 58 now
 
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.
 
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agree as a whole, but there are some globalizations that could be clarified.

for the most part, medicare is not the issue. so medicare ESI if only medicare can be scheduled asap.

it is not the medicare that is the delaying factor. watch out for medicare advantage/medicare with some sort of other insurance as secondary. in that case, the secondary portion is the delaying agent and all of what is said above needs to reflect that.


additionally, some aspects are location dependent (ie what LCD you live in). in this particular area, any MBB<80% is denied.



yes each office should have a dedicated individual whose only task is to work on prior auths and to know each insurers requirements.
 
PAs can be done for most insurances in a few minutes. Most of my patients get an exam and a procedure on the same day. Three weeks out for a procedure is poor practice management IMO.
 
Are you guys waiting 14 days to submit PA request for second mbb, or are you guys submitting right after you collect mbb results and then just scheduling the second mbb for two weeks from the first?
 
"So I'm not getting my injection today? My primary care doctor told me you would do it today. What am I going to do in the meantime, suffer?"

This happens multiple times per day, typically from patients who report back pain "since childhood".
Medicare is my next available or double book tomorrow.

Everyone else is about 1-2 weeks with TPI today, which will hold them over for a few days or so.
 
PAs can be done for most insurances in a few minutes. Most of my patients get an exam and a procedure on the same day. Three weeks out for a procedure is poor practice management IMO.
this is good, but it all depends on ancillary staff and volume,
 
PAs can be done for most insurances in a few minutes. Most of my patients get an exam and a procedure on the same day. Three weeks out for a procedure is poor practice management IMO.
takes HOPD to even hear back from medicare for facet stuff
 
I just haven't tried it, but have heard that often times the 20553 will get paid and the E&M won't.
I believe Blue Cross has a policy that does not allow the 25 modifier if the patient has been seen for the same diagnosis in the past 3 months. So they’d only pay you for the TPI. And if it’s Medicare and you aren’t doing a huge amount of extra documentation, and local only, you may get an audit on those TPIs.
 
"So I'm not getting my injection today? My primary care doctor told me you would do it today. What am I going to do in the meantime, suffer?"

This happens multiple times per day, typically from patients who report back pain "since childhood".
Yup, and then they go and leave a negative review online....thanks for nothing.
 
I just haven't tried it, but have heard that often times the 20553 will get paid and the E&M won't.

I believe Blue Cross has a policy that does not allow the 25 modifier if the patient has been seen for the same diagnosis in the past 3 months. So they’d only pay you for the TPI. And if it’s Medicare and you aren’t doing a huge amount of extra documentation, and local only, you may get an audit on those TPIs.
but theyll pay out if you schedule the procedure the following day or week? Go figure.
Conversely, you can just do the TPI if its a 99203/04/05 same day to bypass the BCBS issue.
 
If you see a patient and do a procedure on the same day you must have another unrelated icd10 to get paid. Doing a 64483? Well ask about the concurrent cervical pain, quick exam note, have a plan for a MBB. The visit is for the neck.
 
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