Q&A: Prior authorization for outpatient services

Q: Beginning in July, prior authorization is needed for certain hospital outpatient services such as blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation. Going forward, how should hospitals approach this change?

A: The burden is on the hospital to obtain this prior authorization, says Ronald Hirsch, MD, FACP, CHCQM, CHRI, vice president of regulations and education for physician advisory solutions at R1 RCM Inc. in Chicago. Hospitals must obtain this authorization even if the physician determines that the procedure is medically necessary. While the physician will need to help by supplying the documentation, ultimately the onus is on the hospital to make sure the preauthorization is complete.

Once you submit a preauthorization, the Medicare Administrative Contractor (MAC) will affirm approval for the procedure within 10 days and provide the hospital with a unique tracking number, which hospitals must include on the hospital claim (but not on the physician claim). If a procedure is urgent, hospitals can request an expedited two-day review, which may or may not be granted, depending on the circumstances, says Hirsch.

If a preauthorization is denied, hospitals can resubmit the request with additional information to support medical necessity as many times as they want. However, claims submitted for procedures performed without the affirming decision will be denied, says Hirsch. Hospitals can appeal the denials.

Editor’s Note: This topic was originally addressed in the July issue of Case Management Monthly.