The cancellation of a prescription by refusal to pay for it is the same as making a prescribing, an act of medical practice. Assume the prescription was cancelled by a doctor in the same specialty as the prescriber. It remains unprofessional conduct to make a medical decision on a patient whom one has never seen, and whose records have not been reviewed.
I would like to see an ethics complaint for unprofessional conduct filed after every denial. The pre-authorization itself is a joke. It implies, the prescribing doctor was not serious in writing his prescription, or only meant it a little. I disagree that the time and effort are built into the encounter fee, without causing a conflict of interest. The fee is to see the patient. It is not to do work for the insurance company. If the doctor is on the payroll of the insurance company and owes a duty of performance, he cannot be 100% committed to the medical interest of the patient.
In any case, here is some advice on trying to make it easier.
Insurance preauthorizations: How to make the process less painful
Practice Management. By Victoria Stagg Elliott, amednews staff. Posted April 5, 2010.
The process can be automated. Or, practices can note what issues trigger a denial, and adjust their processes to quicken and gain approval.
And while insurers normally view precertification as a nonbillable service because it's considered part of a medical visit, evidence of how much time it takes can be used as a negotiating chip with insurers.
"It's supposed to be built into the revenue for the services that doctors are providing, but it can be an administrative nightmare for practices. Every insurance company requires something just a little bit different," said Rhonda Buckholtz, vice president of business and member development at the American Academy of Professional Coders. "But we can simplify the process as best we can."
The first step is to analyze how the office handles the process. Is it possible to get some preauthorizations completed before the patient comes in? Are there insurer-provided online tools that the practice is not taking full advantage of?
For example, Elizabeth Woodcock, principal of Woodcock & Associates in Atlanta, said she worked with an endocrinology practice that entered precertification information into an insurer's online system. But, rather than submitting it electronically, staff printed it out and faxed it, which took additional time.
"Make sure you are using all the automation that the payer allows," Woodcock said.
Experts also suggest creating some kind of tool that staff can refer to with all the policies and procedures of various insurers. This does not have to be particularly high-tech. For instance, Buckholtz has set up three-ring binders at several medical practices she has worked with. The binders can be particularly handy if the person who usually handles preauthorizations is out of the office.
Dealing with denials of the initial request for precertification also can be time consuming, but experts say the situation is another opportunity to look for time savings. Are there consistent issues that trigger a denial? Are certain codes always left off? Are necessary lab tests not being noted?