One urologist's technique for winning the prior authorization game

Dr. WahleWhen it comes to prior authorization, Steven M. Wahle, MD, has developed a stepwise process and takes an aggressive stance with insurers that deny certain imaging tests. “I’ve learned over the years how not to be mad or angry, but just very pointed that this is a patient care issue,” the Cedar Rapids, IA urologist said.

Dr. Wahle describes his successful technique in dealing with payers by phone as follows:

• Once you are certain that a given test is clinically warranted, come to the phone meeting well prepared.

• Ask to speak to the person who makes the decisions. “I don’t want to talk to a nurse practitioner who doesn’t have the authority to do the appeal process. I always ask for the medical director, and sometimes that takes another call,” he said.

• Explain who you are and provide your credentials.

• Explain the clinical situation in great detail. “The point of that is, I’m letting that reviewer know that this is a patient I know face to face and have a relationship with.”

• Emphasize that the test is the standard of care in your community.

• Explain that the patient will be informed that the payer is denying the test and indicating that it’s not the standard of care in the community.

“Those are the pointed comments that I make,” Dr. Wahle said. “I’ve not been turned down. I’ve not had a denial.”UT

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