Surgery pre-certification, prior authorizations

Follow these steps to handle the surgery pre certifications and prior authorizations. Know the difference between pre-certification and prior authorization.

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Conclusion 

  1. Always perform eligibility checks or precertification checks before starting the cumbersome process of prior authorizations.
  2. Handle as many Prior authorizations as you can by yourself. Do these on behalf of your partners before sending them your order.
  3. Always submit as much supporting documentation as possible. Do this for each care plan order prior authorization request. This reduces denials and delays.
  4. Automate the prioritization process as much as possible. Spend your time only on reviewing the outcomes of automation.
  5. Maintain correct statuses of each prior authorization needed/submitted. Either use a spreadsheet with Reminders, or a Calendar with Reminders, or simply use a software like EZHCRM.

Surgery scheduling prior authorization steps

During surgery scheduling, you will have one or more of the following care plan orders.

  1. Surgery procedure orders 
  2. Laboratory procedure orders
  3. Imaging procedure orders
  4. Medical clearance referral order
  5. Specialist clearance referral order
  6. COVID clearance referral order
  7. Medication orders
  8. Diet / Nutrition orders
  9. Device / Implant requisition orders
  10. Transportation orders
Surgery scheduling care plan order for prior authorization

Based on your surgery patient’s insurance, you will need to handle surgery prior authorizations 

  1. Check patient eligibility (pre-certification) for each line item in the care plan order. If the payer responds to the pre-certification request with a denial, discuss next steps with the patient and the surgeon.
  2. If the patient is eligible, check the insurance plan documentation. Each insurance payer has their own rules, conditions etc. These rules do change often. Do not rely on an old copy of the payer’s documentation. Each time, find out whether a care plan order item (procedure, device, medication, transportation etc) requires prior authorization.
  3. Pre certification does not guaranteed for the surgery. Submit prior authorization request for each care plan order line item. Make sure to send medical records and physician documentation to prove medical necessity. 
  4. Each insurance payer has their own response timelines. On a regular basis, check for approvals or denials.
  5. On receiving a denial, appeal the payer decision by submitting even more supporting documentation. Enlist the help of your physician for this. Otherwise, submit a prior authorization request for an alternative / substitute as suggested in your payer denial response or by your surgeon.

Handling emergency procedure prior authorizations

If it is an emergency procedure, the surgical coordinator can skip the pre-certification process. You can try to get the prior authorization retroactively after the surgery. 

Various payers stipulate that such prior authorizations should be obtained between 24 and 72 hours after admission.

Handling prior authorizations to reduce surgical scheduling delays

As a surgery scheduler, you are expected to get prior authorizations only for the procedures your office will perform and bill for. 

So, why do I recommend handling prior authorizations for orders that your office will not deliver nor bill for? Simple. Do this to reduce surgical delays. You retain more control of your surgery scheduling process.

Let’s say that your surgeon ordered a laboratory procedure to be done. Your surgeon needs results gathered before the surgery date. 

  1. You ask the patient to get you the laboratory procedure results before the surgery date or before the pre operative appointment date. The patient gets the laboratory order script from you / your office.
  2. The patient takes their own sweet time in making an appointment with the laboratory. Ultimately, the laboratory’s appointment scheduler books an appointment for your patient. 
  3. The laboratory then has to gather accurate patient information from the patient. The laboratory also has to obtain actual laboratory order script that your doctor wrote, from the patient.
  4. Based on your surgery patient’s insurance, the laboratory billing team or coordinators will need to handle laboratory orders’ prior authorizations. This follows the same number of steps along with the same chances of denials as mentioned before.
  5. In case of denials, the laboratory staff has to resubmit the prior authorization. They have to submit additional, supporting documentation. This documentation comes from your doctor (ordering physician).
  6. The laboratory staff then asks the patient to gather this information. Or, they fax/call your office to get the additional information. Once the laboratory receives additional information, they restart the prior authorization process.

To avoid this back / forth, handle all necessary eligibility and prior authorization steps yourself.