As patients, we are often referred by our doctors for high-tech imaging tests, such as MRI, CT Scan, and PET scan. While the doctor may feel these tests are necessary, we must remember that these tests are very expensive, therefore, most insurance companies require a “prior authorization” before they will cover the tests. Most have contracted with a third party reviewer – a company whose mission is to review each case for medical necessity.
The process usually starts with a request form that is faxed to the third party reviewer. The clinical staff person reviews the request and makes a decision on coverage. Communication for the approval or denial is sent to the requesting doctor at this point. If the test is denied, the provider is guided to file an appeal for coverage. The fastest way for a doctor to appeal is to call the third party review company and speak, “peer to peer”, with another clinical person. During these calls, questions are asked, and medical updates are easily shared. It gives the doctor a chance to make their case by actually speaking to someone, vs. faxing forms or medical records. The decision to approve or deny is usually made by the end of the call, giving the doctor and patient more time to plan the next step in treatment.
If patients experience delays in getting answers about their high-tech imaging requests, we recommend they call their doctors and ask that the peer-to-peer phone call be made ASAP. Most doctors’ offices have the phone numbers to call and should be familiar with the procedure.