An approach to prior authorization insurance denials neurosurgery gas examples matter


When Ms. Mary Smith (not the patient’s real name) started her new job several years ago, she purchased the premium insurance policy that her company provided. power company near me Recently, she developed severe neck and left arm pain. Imaging of her neck with a Cervical MRI demonstrated a large disc herniation at C5-C6 pressing on her left C6 nerve root. 1 unit electricity cost in bangalore Despite attempted non-surgical management including steroids, pain medication and physical therapy, Mary continued to suffer severe intractable pain and weakness in her left arm. gas oil ratio calculator Nearly three months after onset of her symptoms, she presented to a neurosurgeon. Clinical evaluation and review of radiological imaging suggested intractable, severe radiculopathy caused by the C5-C6 disc herniation.

She was scheduled for surgery the following week. u save gas station grants pass However, her “premium” insurance company denied her surgery, claiming that “a physician to physician (peer-to-peer) conference call” was needed. The denied claim cited “lack of sufficient non-surgical management and lack of documentation.” Looking back at the patent medical record all these items had been addressed. Still, the claim was denied and the surgery delayed-leaving the patient to suffer needlessly.

Starting in the 1980s and continuing today, all health care insurers, including Medicare, workers’ compensation programs and private health insurance carriers, have increasingly relied on utilization management (UM) strategies to contain costs. gas utility worker Such strategies have included physician gatekeeper programs, the necessity of second surgical opinions before operative intervention, and prior authorization (PA) for diagnostic tests as well as treatments. Physician practice time associated with UM is estimated at 14.6 hours of dedicated time per practice per week, totaling more than $68,000 per year per practice. 1

Although dependent upon the particular test or intervention, there is evidence that the rate of first-time insurance denials is increasing over time. gas x chewables reviews A recent retrospective review of 1,054 patients evaluated at a single institution for laparoscopic gastric bypass surgery demonstrated the rate of first-time insurance denial for surgery nearly doubled between 2001 (9.9%) and 2005 (19.9%). 2 Another recent report demonstrates a wide range of denial rates, from very low for patients with cauda equina syndrome (multiple nerve root compression) to nearly 17% for lumbar fusions, highlighting the variable nature of such denials even within the relatively narrow field of lumbar spine surgery. 3 Six-fold variation in denial rates, related to geographic region and payer, have also been documented in the literature. 4-5 As a result of their often unpredictable nature, physicians are increasingly investing more time and resources toward strategies to combat UM and PA denials.

Advocacy is one part of the solution. electricity rate per kwh philippines The CNS and AANS have joined with the medical community in calling for the standardization of the PA process across diagnostic tests, interventions, payers and providers. Unfortunately, the diversity and complexity of unifying such processes will likely take much time and investment of resources from all parties.

• During the appeal process, physicians can ask for the credentials of the payer representative who initially denied the request. Often these representatives are either not physicians or not in active practice within the same field of subspecialty. gas in babies In such cases, the requesting physician may ask to speak with a representative active in practice and within the same subspecialty.

At a time when it has become increasingly difficult to obtain first-time pre-authorization for necessary diagnostic tests and interventions, physicians must be increasingly facile in maneuvering UM processes. By increasing our familiarity with national and payer guidelines, standardizing our practice’s documentation, and aggressively rebutting denials, we may continue to advocate for our patients’ best interests and provide outstanding quality and outcomes within our complex and ever-changing health care environment.