Prior Authorization Denials: Demanding Review By Board Certified Physicians

Prior authorization denials deserve intense scrutiny.

Obviously, appealing authorization denials greatly assists the patient access care their provider recommends. However, in a broader sense, prior authorization appeals is one of important ways that providers communicate, educate and maintain a sense of active partnership in healthcare delivery.

State and federal laws likely dictate peer review of denials. But peer review may be defined differently by different carriers.

Case management laws are very important to know and use in pursuing appeals. However, citing legal violations is an in-depth process. For routine problems of securing a high quality utilization management review, the Utilization Review Accreditation Standards provides a number of protections which many carriers have agreed to abide. These standards can be used in a number of ways, including citing standards in phone calls and incorporating URAC information in written correspondence with non compliant carriers.

One of the most important URAC standards which can be used to demand quality case management review is the requirement that utilization review appeals be decided by a board certified physician.

URAC’s utilization review accreditation program is explained at http://www.urac.org/healthcare/accreditation and includes the following frequently asked question regarding reviewers’ necessary credentials:

Do all clinical peer reviewers performing expedited and standard appeals need to be board certified? Yes. For those that are physicians, they must be currently board certified by a board recognized by the ABMS or ABOS. “Board eligible” does not meet the standards.

Making sure that your carriers are compliant is easy. First, go to www.urac.org to see if that carrier is accredited by URAC. If so, they have agreed to abide by the standards and should be willing to supply the name and credentials of the reviewer upon request. If you discover that a reviewer denying care is not board-certified, you can file a complaint with urac.org and initiate an investigation of that carrier’s utilization management program.

If you want to cite URAC in your case management appeals, up-to-date standards are available through a URAC subscription service. You can download a recent version at the Department of Labor website at www.dol.gov/ebsa/pdf/MHPAEA190.pdf.

Some of the other important utilization review standards include:

• URAC Standard 3, “Review Service Communication and Timeframes,” requires organizations to respond to communications from providers and patients within one business day.
• URAC UM Standard 17, “Prospective Review Timeframes,” requires prior approval, or prospective reviews, to be decided as soon as possible but within 72 hours of a request involving urgent care, and within 15 calendar days of a request involving nonurgent care. Retrospective review decisions must be issued within 30 calendar days of the request and concurrent reviews must be decided within 24 hours of a request for urgent care and four calendar days of a request for nonurgent care.