Obtaining Prior Authorization: 3 Success Strategies

Working in a practice that offers multiple on-site ancillary services, I often get the pleasure of talking with insurance company doctors in order to get “approval” for medically needed testing.

Here are a few of my tips based on my experiences:

1. Make the call
The first strategy insurance companies employ is to make it inconvenient for you to gain approval. They know the hours and time demands we all have, and they probably figure that many of us just will not have the time to call. 

To make the most of your time spent dealing with prior authorization requests, ask your staff to take on the upfront part of the call. You should only get on the call once a doctor is on the line and ready for you to discuss the need for the ordered service.  Let the doctor wait for you, not the other way around.

2. Be nice
Most of the doctors you are talking to will approve what you want as long as you have a good medical reason.  Don’t start off with a bad attitude.  It will only make things harder.

3. Play their game.
In some cases, you may do everything right, and the doctor still says they will not pay for the test.  Remember, the doctor is denying “payment” not “treatment.”   

The insurance company's primary goal is to keep the premiums people have paid them.   Turn the tables on them and suggest the most expensive way you can think of to get a test done. Mention that you can just send the patient to the ER for further evaluation and to get the necessary CT, ultrasound, etc.  Or, mention that you will just send the patient to a specialist who will order the same test.

Instantly, the doctor on the other end of the line will see dollar signs adding up in his head and he will be more likely to approve your request.

If all else fails, I always tell the doctor I will let the patient know about the denial and I will document in the chart.  While they claim they have no liability, this sometimes will make them change their minds. 

I have about a 95 percent success rate with these approaches. When I do receive denials, I often send patients on to specialists for consultation or for re-evaluation for other testing or treatment options.  In the end my goal is to get the needed care for our patients.