Getting paid: Watch for denials related to stricter payer prior authorization policies

Why This Topic Matters

The topic is important for practices that depend on accurate prior authorization, especially when the final procedure differs from what was requested or when payer policies are stricter than expected. It highlights workflow, documentation, and payer oversight issues that can affect reimbursement and access to care.

Article Sections

1. Denials tied to prior authorization mismatches

   Explains the general problem of claim denials when the performed service differs from what was authorized. Focuses on orthopedic and spine practice revenue cycle concerns.

2. Stacking codes in the authorization is one option

   Describes one approach practices may use when more than one service is possible during a procedure. Discusses payer response and related authorization challenges.

3. Doctor training is key

   Covers the importance of surgeon communication and staff coordination when a planned service changes during a case. Emphasizes internal workflow and timely notification.

4. Get the coders involved

   Addresses how coding staff can support more accurate authorization requests before submission. Notes issues that can arise when non-coders handle the process.

5. OIG calls Medicare Advantage payers to task

   Summarizes an OIG inspection report concerning Medicare Advantage prior authorization denials and delays. Reviews broad findings about payer policies, documentation, and processing problems.