One of the things that’s come up recently that I’ve had some issues with is people dealing with pre authorizations. This could be a pre authorization whether it’s a I don’t know, health insurance like ASH, maybe Optum, maybe a VA client.
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Greetings, everyone. This is Sam Collins, the coding and billing expert for acupuncture, the American Acupuncture Council and you. One of the things that’s come up recently that I’ve had some issues with is people dealing with pre authorizations. This could be a pre authorization whether it’s a I don’t know, health insurance like ASH, maybe Optum, maybe a VA client.
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And it’s always, what are they looking for? So let’s go to the slides. Let’s talk about that. What is required for a pre authorization? What in the heck are they looking for? How do we make sure to kind of streamline this? Make it easier for ourselves and ultimately know what are they looking for. And I think that’s what’s really important.
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So when you’re talking to pre authorization requests, you got to think of who does this come from? Well, number one, I think people think of the plans similar to ASH, American Specialty Health Network. That’s all over. And of course, those require pre authorization, particularly unless you’re a tier six. It could require authorizations after the fifth visit or eighth visit.
So what are they looking for? But we’re also running into issues. Optum Health, who manages United Healthcare is requesting, and we’re seeing it obviously from community care, meaning the va. And this includes Tri West on the West Coast, or Optum on the East Coast, which of course already is there ’cause we know Optum does require that.
But then there’s other plans, I’m sure you’re noticing Aetna, blue Cross, blue Shield, Cigna, and others. are beginning to put this in place. Not everyone, but whenever you run into this issue, one of the difficulties is trying to understand how do I make sure to get the care authorized, make sure I’m not running into a hassle and creating much more work for myself.
So what do they want? Why do they want it? Well, what they want really is a plan of care. What are you expecting to do? What are they expecting outcomes? So you do have to really write up a plan. I want to see this patient two times a week for three weeks or whatever numbers, but it has to be specific. It cannot be open ended.
The ultimate thing that they’re going to realize or look at though, is are you making the patient better? With pre authorization, it often is not the first visit, but it’s follow up visits. Even ASH will allow you about five. So what they’re looking to see is that, well, is this care working? Is it going to make the patient any better?
And they’re looking really, if nothing else, the why? They’re looking to avoid maintenance, supportive, or palliative care. It’s care I believe and I think is useful, but insurance, of course, So they’re always concerned that it’s going to give them just feel good. Now what I find funny about that is how much care that’s medical, meaning medicine, that’s curative?
Or is it maintenance? I mean, if you think of it, if I take blood pressure medication, am I curing it? Or am I just maintaining it low? Well, think of pain management. Well, maybe I’m not curing the reason for pain, but if I can maintain it, isn’t that a good thing? Kind of interesting how that kind of works in that way for us.
However, what I want to focus on is what are they looking for? So when you start doing a pre authorization, there’s some highlights you want to have. Medical necessity, when we look at this from American Specialty Health, and now this is not my opinion. This is taken directly from their guideline. The number one thing they rely on is your diagnosis.
And this is going to be true for anyone. Make sure your diagnosis is one that they cover. One big reason things aren’t covered is you don’t have the proper diagnosis for your care. Notice that they don’t cover everything, but know the things that they do cover and focus in on that. They do pay attention, however, to the past medical history, severity, complexity, Acuity, is it recurrent or chronic?
That does make a difference. When that is in play, it can create a greater need for care. But they also pay attention to comorbid factors. What are things underlying? Maybe I’m not directly treating it. But it’s causing the patient to be more difficult to respond. Maybe they’re diabetic. Maybe they have MS.
Maybe they’re very overweight. Maybe they’re very deconditioned. Anything you can think of that is causing it to take longer is important because otherwise they’re assuming everyone gets well in a few visits. And they do look at your exam findings, whether it’s range of motion, palpatory, orthopedic testing, orologic testing.
And remember for acupuncture, they do pay attention to tongue and pulse. Those are important, but you know what they really want to know? Within all these factors, what are the functional limitations of the patient? What is it causing the patient to have difficulty doing? Because pain always inhibits function.
So I always think along the lines of all these things leading to how are we making the patient better? And better means functionally, not just, I feel better. And think ultimately of what the goals are. So if you kind of start putting this together as a template, this is going to allow you to start to think of what things they’re looking for.
Now this is just American Specialty Health. Let’s take a look. This is the one from Cigna. Now I’m showing in big format here, but notice Cigna says, medically necessary services must be delivered toward defined, reasonable, and evidence based goals. That’s that first bullet. Medical and assessed decisions must be based on patient presentation, diagnosis, severity, and documented clinical findings.
Continuation of treatment is contingent upon progression towards defined treatment goals and evidenced by significant, objective, functional improvement. Do you notice how much they’re bringing in that function? That’s what you want to focus on. So notice it says, examples, outcome assessment scales, range of motion.
So notice, is this very different? From what we saw with ASH, not really. In fact, take a look at the last bullet. It says, medically necessary service, including monitoring of outcomes and progress within change in treatment or withdrawal of treatment if the patient is not improving. So notice the outcome is what they’re looking at.
Show me what they’ve gotten so far, how they’ve changed, what are the expectations, or what are the expectations based upon guidelines? Here’s more of it from Cigna. And you’ll notice again, the emphasis here, measuring progress. Pain scales. That helps. But a pain scale without context is not very good. We want to have interference with daily activities, functional outcome measures, length of relief after treatment.
And you know how a lot of patients feel better for a few hours, a lot better. But by the next day, they feel the same. If you just report how they felt the next day. Your care doesn’t appear to be working, but highlight those factors. But notice tenderness, palpation, range of motion. Here’s what I’m highlighting.
It’s not very different. Maybe semantically there’s some differences, but ultimately the same things they’re looking for. Even the VA jumps in on this. The VA says significant, durable pain intensity decrease. So we want to see pain decrease, but not pain by itself. When pain is better, function is better.
So when a person says they feel better, ask the question, what can you do now that you couldn’t do before? Maybe tying your shoe, driving the car, whatever the case may be. But notice it says meaningful improvement on validated disease specific outcome instruments. Acupuncture works well. Let’s make sure to demonstrate that.
Not just by what we verbally hear from the patient, but validate it. So we want to also highlight any documented elusive, documented lesser use. I don’t care if it’s over the counter or otherwise. If they’re taking less, that’s helpful. And then also look at any objective measurements. Again, things on your objective exam.
And again, you’re going to notice, well gosh, this is the VA, we did Cigna, we did ASH. Does it all kind of come out to be the same? Yeah, in fact, they even say here, include any barriers to recovery such as complicating conditions or comorbidities. But also how the patient has changed to date and how the care will continue the same trajectory.
At the end of the day, show me the patient is getting better. I think the simplest thing to do is always have outcome assessment tools at the ready. Whenever a patient first visits, that should be the first visit, and probably once a week or every two weeks at least, because your care is working. We want to show that it’s gaining.
by having direct measurements. Now you’re going to hear the term data driven care. It’s the data of what you collect. Tracking restrictions on activities of daily living is probably the best way. So you’re going to use what are called patient reported outcome measurement instruments. And there’s lots out there.
General pain index, specific functional scale, the short form for pain interference. There’s a long form. And then pain rating scales. Those are good. Oswestry, but everything has to fit within a goal. Now, some of you who are members in our network, remember our AccuCode has these on there all for you to use and how to use them, but ultimately let’s take a look at how they set up.
Here’s the general pain index. To me, one of the simplest, but most effective. Notice this is not a pain scale. It’s not about how much the person’s in pain, but how the pain affects their family and home responsibilities. They’re recreation, social activities, employment. In other words, if it’s a 0, they’re doing fine.
But a 10 means they’re a mess, and all we’re looking at is a number. The higher the number, the more dysfunction. As the patient improves, the number should reduce. Now you’ll see at the bottom it says the threshold score is going to be 5, meaning that if a person’s score is 55, they’re not better until at least they’re 50 or lower.
It’s got to be a 5 point difference. What you should notice initially, It’s a high number that will drop a lot, at least at the beginning, and then it begins to trickle. Now, that doesn’t mean because the trickle is happening you’re going to stop, but it just shows you’re continuing. An easy way of demonstrating it, because if you rely on the patient saying they’re feeling better, that’s not really going to give us enough evidence, because feeling better in what way?
You ever had a person tell you it’s a 10 but they’re almost functional and another person’s 5 is dysfunctional? So that’s why the pain scale is not as accurate. It’s the pain scale with function. So General Pain Index. In fact, the VA has one they prefer now. It’s called the Pain Interference Short Form.
In fact, you know what this is? It’s the short form for the General Pain Index. Notice, it’s the same six questions, but it just has a five answer. This is what I would say you probably do once a week, maybe the other one every two weeks. All this is doing, though, is giving evidence of how your care is working.
When you are seeking an authorization of care, the best way to authorize more care is to demonstrate how much the patient has changed. And then what the continuation is going to continue, the projection, if we’re improving 10 points or so each time we do this, there’s no reason to discontinue until it begins to flatline and there’s no further improvement.
Bottom line is they’re looking, are you making the patient better? That’s what they care about. Not about how they state it, but notice every single one focused on function. If someone says they want function, Give them function. Use an outcome assessment. Make it part of your daily note. In fact, there’s some new rules that are going to help us with pre authorization.
Now, these rules technically don’t take effect until 2026, but this is the movement. This new federal rule requires that they streamline and disclose more information. Do you ever notice sometimes, They don’t give enough information, I’m providing a lot of it here, but we want to see a process where if you’re participating in any federal plan, this doesn’t include VA and others, they must now respond to an expedited process within 72 hours.
But never greater than seven days. Now, many of them say, Oh, yes, we respond within, you know, five days. We know how that works. I mean, think of some of these VA claims you’ve probably requested. They can take a month. Now, they’re requiring that they respond sooner. ASH can respond pretty quickly, but it’s almost always negative.
So, if that’s the case, they must also include their reasons for denying. Often, when I deal with an office on getting pre authorization when they’ve been denied, The best way that can help them is I take a look at what was denied and the why to make sure when we make the next request, we hit the points that they want.
Remember, when someone wants A, B, and C, give them A, B, and C. I don’t care what you think, get what they want. Now that doesn’t mean if you like doing A, B, C, D, E, and F, great, but their focus is A, B, C. Give them that as the primary. Realize now you’re going to have a little bit more of a framework to look at.
Most often when they do give a denial, they’ll give a little bit of this. Now under federal rule, it’s going to be required. Don’t be afraid of it. Your care works. Demonstrate it. As always, the American Acupuncture Council Network is here to help. If you need some one on one help, want to make me part of your staff, join our network.
I hope to see you. Otherwise, everyone, I wish you well.