Everyday our office is overwhelmed with surgical and MRI prior authorization denials for patients we anticipate on treating. These denials, which often occur at the worst possible time, not only shock our patients, but also scare them as these denials can lead to major roadblocks in accessing care they desperately need. Far too often do we have to scramble the day before surgery in order to get a procedure covered appropriately, despite having done everything correctly.

These denials can be triggered for a variety of reasons. Most commonly we find that inconsistent or inadequate documentation is the primary reason for a denial. This is not meant to be a knock on other physicians and their staff. Rather, navigating the prior authorization landscape requires carefully selected language and timely submission of supporting documentation in order to optimize chance of approval.

We strive to avoid a denial ever happening, and we think that you should too. What can you do as a patient to maximize your chances of insurance covering your procedure?

  1. Find a doctor’s office that knows what they are doing

Make sure to get in contact with the team that handles the authorization at your doctor’s office. Make sure to ask if any pre-certification or prior authorization is required before the surgery. Because there is no national oversight to the prior authorization process, the criteria for surgery can change at a moment ’s notice. Working with a doctor’s office who understands the process and how to deal with different policies is important.

  1. Make sure you understand your insurer’s medical policy for the surgery.

This medical policy describes how coverage decisions are made for the particular surgery you want. Each insurer has a medical policy for surgery. You can get this policy by asking your physician’s office or asking your insurance company.

These criteria are the bread and butter of any denial. Cases can get denied for what most think are laughable reasons. For example, a physician can fail to mention that you didn’t have end stage osteoarthritis (maybe because you are 27), or that you didn’t try NSAIDs or rest prior to surgery. By reading and understanding a denial in conjunction with your plan policy and criteria, you can know exactly how to address it.

  1. Ask what the appeals process is.

Does your doctor’s office have an appeals process? How do they handle it? After the appeals process is exhausted, how much are you on the hook for? This should be asked regardless if you are seeing an in or out of network provider. Keep in mind, sometimes physicians have patients’ sign waivers stating that if parts of the procedure are denied, they are responsible for those charges.

You can also get a denial after surgery (even if a prior authorization was done). Everyday our office gets panicked emails from patients because they have been notified that their insurance company denied their surgery. Like mentioned previously, we typically see these denials for reasons that are easy to fix.

Transparency isn’t just for Southwest flights. Patients should never feel weird or awkward asking about how an office handles this process. Despite our best efforts, we are unable to predict how this landscape will change. While we hope that things will get better, all we can do in the meantime is adapt, adjust and overcome to beat insurers at their own game.

Dr. Wolff’s office has dedicated staff members for prior authorizations, appeals, and insurance inquiries. We work with our patients to make sure that the process is smooth and that when we run into bumps on the road, we know how to continue the push forward.

Helpful links:

Success stories in obtaining prior authorization

NY Times: Adventures in Prior Authorization