Prior Authorization
Prior authorization checklist
You should not rely on yourself, your medical colleagues, or other clinicians in your practice to manage complex and time-consuming prior authorizations. Doing so not only reduces valuable time with your patients, it affects your ability to use that time for billable services. Instead, you can take the following steps.
Have dedicated staff (clinical or administrative) in charge of obtaining prior authorizations.
Have these same staff manage insurance denials or appeals because they know the most about the specific therapeutic area, patient, and therapy.
Have your authorization staff draft letters for medical necessity to be signed by physicians or advanced practice clinicians.
To increase prior authorization success rates, keep documentation on hand and ready for submission that demonstrates patients have tried maximum doses of approved therapies. In addition, maintain documentation showing patients have received stepped therapy and have not demonstrated improvements. This will make the prior authorization process simpler, easier, and more likely to result in reimbursement.
Reference
Versel N. Build your own infusion clinic. Biotechnol Health. 2005; 2(1):35-36, 39-40. Available at
Although it is tempting to skip over prior authorizations or just invest minimally in them, it is vital that you do not. Without proper prior authorization, your practice will not get paid for expensive infusion services. What is the potential impact on your bottom line? A single claims denial or an unreimbursed case could mean the loss of $3,000-$4,000 in revenue, at a minimum.