A familiar complaint many orthopaedic surgeons hear from exasperated staff is, “I couldn’t get this MRI approved—the insurance company wants a peer-to-peer review.” The surgeon must then get on the phone with the insurance company, and after providing additional information about the case, is often successful in obtaining approval for the procedure. However, this process is not only a waste of surgeon and staff time, but it also results in delayed treatment for the patient.

Obtaining precertification (depending on the payor, it may be referred to as prior authorization or preauthorization) for MRIs, computed tomography (CT), and at times, surgery has become more difficult. The good news is that by understanding payer guidelines and tweaking physician and staff workflow, the precertification process can be streamlined, resulting in increased approvals and reduced peer-to-peer reviews.

Understanding payer policies
The frequency of peer-to-peer reviews correlates directly with poor documentation (ie, the office visit notes do not substantiate the need for the requested imaging or surgery).

Major payers publish their medical policies on their websites; however, these policies do change from time to time. Fortunately, payers announce these changes in their newsletters. To ensure that your practice is aware of these changes, assign staff to review payer newsletters on a monthly basis, paying particular attention to policies that impact the practice.

As a best practice, update electronic health record (EHR) templates to incorporate medical necessity guidelines, including Medicare’s Local Coverage Determinations (LCD) and commercial payer guidelines for insurances the practice accepts. Examples of payer medical polices for total hip arthroplasty include the following:

• Aetna: http://aet.na/2Ins37M
• Cigna: http://bit.ly/2Gkyp7D
• UnitedHealthcare: http://bit.ly/2p6Jtxy
• The UnitedHealthcare guideline also references MCGTM Care Guidelines (http://bit.ly/2FvDkW1). MCG is said to be used by many insurance companies.

Because the policies are more similar than they are different, first highlight all the similar requirements between the payers and then highlight any requirements that are unique to a particular payer. Combine the requirements and build them into the EHR template (eg, total hip arthroplasty).

Surgeons who do not have an EHR or who still dictate should create a summary document with all the requirements for each surgery and ensure those criteria are dictated into the note.

Most major payers either use AIM Specialty Health or eviCore healthcare (formerly MedSolutions) for imaging authorizations. Both companies publish their medical guidelines on their websites (http://bit.ly/2FINWA3 and http://bit.ly/2p4lwXD, respectively).

For example, the eviCore policy for shoulder rotator cuff tear indicates that a radiograph is required before advanced imaging can be approved. Failure of 6 weeks of provider-guided conservative treatment within the past 12 weeks is also required, unless it’s an acute shoulder injury and the advanced imaging procedure is a consideration for surgery.

The EHR template for ordering a MRI for a rotator cuff tear, therefore, would need to include the results of the patient’s previous plain film radiographs, and indicate that the patient had failed 6 weeks of conservative treatment, outlining the specific treatments and their outcomes.

Incorporating payer medical necessity requirements into the EHR templates ensures that the components of medical necessity have been documented. The result is fewer denials or requests for peer-to-peer reviews.

Submission of precertifications
Rather than calling each payer to ask if precertification is required for a specific procedure, use electronic tools to develop a list of procedures/payers that require precertification. Save phone calls for situations where required precertification is unknown. Most major payers have precertification lists on their website or have look-up tools.

Most payers also allow for electronic precertification, including for surgery. For example, UnitedHealthcare has their own portal (http://bit.ly/2tBGxh8, registration required and then use the Eligibility & Benefits link). Humana uses OrthoNet (www.orthonet-online.com) and Availity (www.availity.com). Many Anthem and Blue Cross companies also use Availity. Aetna and Cigna allow for precertification using Navinet (www.navinet.net). Whenever possible, submit precertifications electronically to save time and speed the approval process.

If staff are routinely calling for precertification, the practice is overspending. According to the 2016 CAQH Index: A Report on Healthcare Industry Adoption of Electronic Business Transactions and Cost Savings, manual prior authorization costs a practice $7.50, while electronic submission only costs $1.89.

Summary
By incorporating payer medical policies into the documentation, the precertification approval rate will increase, the number of peer-to-peer reviews will decrease, and the amount of time it takes to obtain a precertification will be reduced. Utilizing electronic tools for precertification will reduce the amount of time it takes to obtain a precertification, saving the practice time and money. To implement this new workflow into your practice, see the checklist provided in the sidebar.

Cheyenne Brinson, MBA, CPA, is a Chicago-based, senior consultant with KarenZupko & Associates Inc.

Disclosure: Ms. Brinson is a consultant with KarenZupko & Associates Inc., which develops and delivers CPT coding and practice management workshops presented by the AAOS in conjunction with KarenZupko & Associates Inc.

Streamline Precertification Process Checklist

• Sign up for payer newsletters for all payers for which the practice accepts insurance.
• Obtain and review payer medical necessity policies for surgery/procedures.
• Obtain and review medical necessity policies for imaging.
• Build EHR templates to incorporate all requirements for all payers.
• Create a chart of precertification requirements.
• Create logins for all payers’ online precertification tools.
• Provide training for users on how to use the precertification tools.

References:
www.evicore.com/ReferenceGuidelines/17_Musculoskeletal%20Imaging%20Guidelines_V19.0%20FINAL.pdf page 25, accessed January 14, 2018