Challenging the Prior Authorization Denial

Before completing a prior authorization request, you should review the insurance company’s website to ensure you submit the correct information. But if you should receive a denial, here are some tips from the prior authorization verification and enrollment (PAVE) department at CBS Medical Billing about submitting an appeal. Most orthotists and prosthetists reading this likely imagined when they chose this profession that their time would be spent focused on working with patients, helping them walk or grow up straight (scoliosis pun). If seeing the patient was all we had to work on and all we had to worry about, it would be just too much fun. But what comes first is getting devices authorized, and the second step is ensuring the claim gets paid, which I’ll cover in my next column. [caption id="attachment_247170" align="alignleft" width="231"] sebra/stock.adobe.com[/caption] I was shocked by this data from the Kaiser Family Foundation: In 2021, over 2 million prior authorization requests were either fully or partially denied by Medicare Advantage plans. Yet only a paltry 11 percent of those prior authorization denials were appealed. Even more amazing, a whopping 82 percent of the appeals submitted resulted in those denials being overturned. (kff.org/medicare/issue-brief/over-35-million-prior-authorization-requests-were-submitted-to-medicare-advantage-plans-in-2021) This begs the question, why are we accepting rejections of prior authorization requests? Authorizations are being denied for numerous reasons, some as simple as a clerical error or the wrong identification number, slightly more complicated causes like insufficient documentation supporting the request, or in many cases authorizations are just denied in error. Whatever the denial reason, we have an 82 percent chance to get it overturned on appeal. Am I the only one who loves those odds? Why wouldn’t we appeal? If the authorization request is denied, you first need to dig deeper. Call a representative and ask exactly where you can find the policy they are quoting for the denial. It is important to understand the denial to understand how to appeal it successfully. Know your denial appeal rights. How long do you have to appeal this denial? How many levels of appeal are there? What are the submission instructions for the appeal? If you send a hard copy of the appeal, be sure to send it in a trackable manner (i.e., priority mail, UPS, or FedEx). You don’t want to miss a filing limit because the appeal was lost in transition. Write a compelling appeal letter. Summarize the main points of the appeal and request a reconsideration. Review why it was denied by using the exact terms of the insurance company’s verbiage and criteria from the denial letter. Challenge each point of their denial by supplying supporting documentation. Outline the medical necessity and functional benefits of the device. Outline the harms and risk of not approving the device. Attach copies of all paperwork. Follow up consistently. Be sure the appeal was received. This is where your tracking number or fax confirmation comes in handy. Once you have confirmed receipt, follow up regularly and consistently to track the appeal process. Remember to keep a log with names, dates, and details of all conversations and a copy of everything you sent in. To help your patients and your practice, don’t give health insurance companies an easy win. Statistically, you have a great chance for a comeback victory. Erin Cammarata is president and owner of CBS Medical Billing and Consulting. She can be contacted at erin@cbsmedicalbilling.com.

Challenging the Prior Authorization Denial

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Challenging the Prior Authorization Denial

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Certified Prosthetist / Prosthetist-Orthotist (CP/CPO) Gates Prosthetics + Mobility Clinic — Mountain Home, AR

Clinic Manager – Certified Prosthetist Orthotist (CPO) – Rogers, AR

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