Prior authorization isn’t just for in-lab sleep studies. Some third-party payors require advance paperwork for home testing as well.
Sleep medicine providers share the common goal of providing swift and effective care for their patients, but preauthorization for home sleep tests (HST) can sometimes stall this process and siphon resources away from patient care.
Long telephone hold times with third-party payors can interrupt the workflow of administrative staff and can be arduous to document in electronic health records. Faxes containing clinical documentation for preauthorization are often filled out by hand and must be manually entered into the patients’ electronic health records. Some sleep medicine offices hire full-time employees just to take on the extra work of getting HST preauthorization for their patients.
“They make it so that it is expensive for us to get the patient the test,” says Michael Zachek, MD, a sleep specialist who treats patients in Kentucky. “If you can answer the questions [for preauthorization] in 10 minutes, why does it take some providers 15 working days to get the answers?”
Medical office employees report spending hours navigating through individual insurance company’s websites or sitting on the phone, waiting to get through to the appropriate person to seek approval for a relatively low-cost test that is almost always approved.
To avoid unnecessary frustration, here are several easy to follow tips that can help streamline the process.
1. Small mistakes can hold up the preauthorization process, so study the clinical criteria for each insurance company, says Amy Aronsky, DO, FAASM, a sleep physician and medical director of CareCentrix. “Make sure you have all the pertinent clinical information that is going to support the diagnosis that you are looking to make and that the documentation supports the clinical guidelines.”
2. Be aware that insurance coverage guidelines could be changed on an annual basis, so it is essential to check in with the payors regularly to make sure that approval criteria is up to date.
3. Make sure all physician clinical notes are detailed, including data points that payors will commonly ask for, says Heather Barskey, director of support services at Advanced Sleep Management, a management consulting company for medical practices.
“The key is to be careful with your documentation as it is with any prior authorization request,” says Zachek.
4. Administrative staff can consider modifying your electronic health record (EHR) templates to make sure they prompt answers to all the questions that the health plans have. “There may be an insurance company that wants something very specific that you are not asking,” says Zachek.
5. If modified EHR templates are too high-tech, consider creating a laminated cheat sheet or a checklist for all practitioners who are recording clinical records, says Barskey. The cheat sheet could include medical criteria that insurance companies commonly ask for when reviewing preauthorizations. This might include the patient’s body mass index, neck circumference, and history of snoring. Include an Epworth Sleepiness Scale. Don’t overlook documenting the duration of time in which your patients have been experiencing symptoms.
6. After faxing clinical notes, always make a follow-up call 24 to 48 hours later to ensure that the notes were received. If time allows, call every two days to check on your patient’s case, says Barskey.
7. After speaking with insurance companies, record detailed notes from the conversation in patients’ charts. Write down who you spoke with, document phone numbers that connected you to the appropriate person, and ask for a phone call reference number and a pending authorization number. Detailed records can come in handy in instances when the insurance representatives give you incorrect information about coverage, says Barskey.
8. Learn the quirks of specific payors. For example, Barskey says at least one insurance company has a checkbox on its online portal that asks, if your request for an in-lab gets denied, whether you would like to request a HST. If you check the “yes” box, in her experience, the request almost immediately gets approved for a HST—which means that you don’t know if the insurance company evaluated the request to see if an HST is truly appropriate, according to Barskey. “They do everything that they can to get you to switch that over to the home sleep testing.” (Multiple health insurers were contacted for this story but none was willing to provide their perspective on-the-record.)
9. Once the test is approved, it is important to schedule the HST quickly because often the approval is only valid for 90 days. After that window closes, some insurance companies will extend the deadline, but others may have you reapply for preauthorization again.
In the Unlikely Event of a Denial
If you received a denial for an HST, doublecheck that the test you submitted a preauthorization for is actually the one being denied. In some cases, the wrong CPT code could have been submitted. Some tests can have the same CPT codes, which can cause confusion and delay approvals, says Aronsky.
Under the Affordable Care Act, all health plans are required to have an appeal process for denied prior authorizations. According to the American Medical Association, if the health insurance company upholds its initial decision, an external appeal by an independent third-party reviewer may be requested. Providers can also ask for an expedited review of their appeal, in which health plan decisions are completed within 72 hours.1
If your patient is denied the appropriate testing, it can help tremendously to ask for peer-to-peer consultation. Preauthorization for HSTs aren’t often denied, but when they are, a peer conversation can often sway the insurance companies to cover HST. Before the conversation starts, make sure you have the patient’s medical history in front of you. “Don’t assume they are going to deny something just because they say they are going to,” says Barskey.
After all this paperwork the third-party payors typically approve the HST, wasting the time and resources of both the insurance companies and the physicians’ offices. “The insurance companies are probably losing money doing this because the prior authorization is almost never denied,” says Zachek.
Lisa Spear is associate editor of Sleep Review.
1. American Medical Association. Tips to help physicians reduce the prior authorization burden in their practice. 2015:1-5. Available at https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/premium/psa/prior-authorization-tips_0.pdf