Prior authorization is the payer's approval, requested in advance, for certain services. Whether a service needs it depends on the payer and the plan. For the practice, the request is partly clinical and partly administrative, which is where it can stall.
The administrative workflow
- Identify the requirement. When a service is scheduled, someone checks whether the patient's plan requires authorization for it.
- Assemble the request. The clinical team supplies the supporting documentation, and administrative staff prepare the request in the form the payer asks for.
- Submit. The request goes through the payer's required channel, and its reference number is recorded.
- Track. Someone follows up if there is no response and records requests for more information.
- Record the outcome. Dates, approved services and any limits are noted, and the scheduler and clinicians are told.
Where it stalls
Requests wait most often for documentation from the clinical team, or for a response from the payer. Because both are outside the billing office's control, a visible list of pending requests, with the date of the last action on each, helps the right person be reminded at the right time.
Practical habits
- Keep a single list of open requests, with a next step and a responsible person.
- Agree how far ahead of a scheduled service a request should be started.
- Record the reason when a request is denied, so that the practice can decide on next steps.
- Tell the scheduling team about the status before the appointment date arrives.
Decisions about whether a service is medically appropriate belong to clinicians. The administrative workflow exists to make sure their documentation reaches the payer in time.
This article is general information about healthcare business operations. It is not medical, legal or financial advice.
