Today you went to the doctor and he recommended that you start physical therapy and acupuncture. You’re excited to get things going so that you can begin to feel better. You call the physical therapist to schedule your appointment and then you’re told that they can’t schedule you until they receive the dreaded authorization. So you wait and wait and wait to get a call back from the therapist stating that you can finally start your therapy. Two weeks pass by and still no authorization! You just don’t understand why it’s taking so long. Well, let me explain the authorization process to you and then you’ll understand why there’s such a long delay from evaluation to treatment.
After you are evaluated by the doctor, he or she must submit a written report of their findings and recommendations along with a Request For Authorization (RFA). Once this is submitted to the insurance company, the authorization process will begin. However, the first issue begins here because it takes various lengths of time for your doctor to actually submit the report and RFA.
Most doctors dictate their reports, which means that they speak in to a voice recorder and someone else listens to the recording and then writes the report. This process of transcribing can take various amounts of time. It can range from 2 days to a month; each doctor’s process for transcription is different. Next, after the report is actually written, someone else at the doctor’s office must complete the RFA form that actually lists the specific treatments that your doctor has recommended. Lastly, the doctor’s office then must fax over the report and the RFA to the insurance company. AS you can see, this is just the first step in the authorization process, and this alone can take form a couple of days to a few weeks.
Step two happens once the report and the RFA are received by the insurance company. Some adjusters have the authority to authorize certain treatments without sending the request to Utilization Review (UR). Other adjusters are required to send every single request to UR. But regardless of who reviews the request, they have up to 5 days to authorize, deny, or request additional information. Keep in mind that holidays and weekends don’t count. So essentially, this will add another week to the authorization process.
Step two can get very complicated if the person reviewing the authorization request doesn’t have enough information to make a proper decision, which happens frequently. This means that your RFA can get forwarded to a physician reviewer or go to peer review, which can take up to 14 days.
Step three is when your RFA gets authorized or denied. If it’s authorized, a letter will be sent to you and to the requesting physician. The next problem is that most physician offices don’t pay much attention to these authorization letters, which mean that they don’t immediately act on them. For instance, they could receive the authorization o Monday, stick it in a pile with all of the other authorizations, but they don’t get around to reviewing the authorization until Friday. Hence adding another week to the process. Worst case scenario (which I’ve encountered many time), the doctor’s office doesn’t review the RFA determination letter until your next appointment, which is usually 4-6 weeks away!
On the other hand, if the RFA was denied, there’s nothing doctor’s office to do, but there is a process that you can initiate to appeal the decision. The process is called an Independent Medical Review (IMR). This is when you request that another physician review your RFA and make another determination. The form for this IMR process will be included with your denial letter that you receive in the mail.
The final step, if authorized, is scheduling the therapy. Usually all treatments must be referred to an approved provider that is located within the Medical Provider Network (MPN). Unfortunately, you don’t have the freedom to go to any therapist that you desire. Many times, the doctor’s office will refer your authorization to a “placement vendor”. These vendors act as a third party to set-up and schedule your therapy with an approved provider. And this process of coordinating your referral to an approved provider can take a couple of days to about a week or so.
As you can see, there are a lot of steps to the authorization process that you were probably unaware of. This process can take anywhere from one day to many weeks. This is the reason why it takes so long for you to get the authorization to move forward with the treatments that your doctor recommended.
Lolita Korneagay, RN, BSN, MBA, ALNC is a Registered Nurse and Patient Advocate that has over a decade of experience with assisting patients recovery from illness and injuries. She provides expert medical consulting to patients, employers, insurance companies, and attorneys regarding healthcare claims. For a consultation, visit www.korneagaylnc.com for additional information.