Introduction: Prior authorization is a complex and often frustrating process that physicians face on a regular basis. Of particular concern is the lack of information included in denial letters and appeal processes. Appropriate information to understand or appeal the denial itself is rarely included. Patients and physicians are informed that a surgical procedure has not been granted prior authorization, and no justification as to why the denial took place or an alternative treatment option is provided. Our discussion deals with salient clinical checklist information, modality data and clear surgical plan formulation upon submission.
Methods: Precise clinical data collection and submission in spinal diseases optimizes the process of insurer affirmation and acceptance. The appeals process of contested surgical claims can be mitigated with proper and concise outlined information. We utilized a pre-programmed checklist of clinical discernments and radiological modalities to complement the surgical objective.
Results: Retrospective review of our checklist-based submission system-wide neurosurgical spine practice (>800 case submissions/year) has revealed a less than seven percent (7%) deniability claim with greater than ninety percent (>90%) successful appeals deference following insurer contact.
Conclusion : The proposed checklist of submission clinical criteria and modality-based support has afforded significant competency in obtaining insurer affirmation and approval toward interventions.
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