Prior and Retro Authorization Services

When a service is performed without prior authorization, whether due to emergency circumstances, administrative oversight, or payer system errors, the resulting claim is typically denied. Retro authorization is the process of obtaining approval after the service has already been delivered.

This requires a different approach than prospective auth. We prepare detailed clinical justification explaining why the service was medically necessary, why prior authorization wasn't obtained, and why the claim should be approved retroactively.

The AMA's 2024 Prior Authorization Physician Survey found that 94% of physicians reported care delays due to prior authorization. Beyond patient impact, the administrative burden is staggering. The average physician practice spends 14 hours per week — nearly two full working days — completing prior authorization requests. That's physician and staff time diverted from patient care to phone trees, fax machines, and payer portals.

Revenue impact per denial. When a prior authorization is denied or not obtained, the claim is denied at 100% of billed charges. For a procedure billed at $2,500, that's $2,500 lost — not $25 to $30 in rework costs, but the entire payment. These denials feed directly into your accounts receivable aging buckets. And if the payer classifies the service as "not medically necessary," balance billing the patient may not be an option.

Staff burnout. Prior auth is the single most-cited reason for staff burnout in medical practices. The repetitive cycle of calling payer utilization management departments, waiting on hold for 30 to 60 minutes, providing clinical information over the phone, then receiving a denial letter requiring a peer-to-peer review — this process drains staff morale and drives turnover. Replacing a trained authorization coordinator costs $3,000 to $5,000 in recruiting and training.

Patient abandonment. Studies show that 34% of physicians report patients who abandoned a recommended course of treatment due to prior authorization delays. That's not just lost revenue — it's a clinical outcome issue that can expose practices to liability.

Authorization requirements vary by payer, plan type, and even the specific plan tier. However, the following categories almost always require prior authorization across most commercial payers and Medicare Advantage plans.

Advanced imaging. MRI, CT, PET scans, and nuclear medicine studies. Most payers route these through radiology benefit managers (RBMs) like EviCore, AIM, or NIA. Each RBM has its own clinical criteria and submission portal. We know which RBM each payer uses and submit through the correct channel.

Surgical procedures. Any elective surgery typically requires auth. This includes orthopedic procedures (joint replacements, arthroscopy, spine surgery), general surgery, and outpatient procedures like endoscopy or colonoscopy for certain payers. We submit with operative notes, conservative treatment history, and clinical guidelines to meet medical necessity criteria.

Specialty medications. Infusion drugs, biologics, and specialty pharmacy medications often require both prior authorization and step therapy documentation (proof that less expensive alternatives were tried first). We maintain records of the patient's medication history to satisfy step therapy requirements.

Genetic and molecular testing. With the rapid expansion of genetic testing, payers have tightened authorization requirements. Many require documented family history, genetic counseling records, and evidence that results will change the treatment plan. Our eligibility verification process flags authorization requirements during the pre-visit check so nothing is missed.

DME and prosthetics. Power wheelchairs, CPAP machines, prosthetic limbs, and custom orthotics require detailed documentation including physician certification of medical necessity, measurement records, and expected duration of need.

When a payer denies an authorization request, they often offer a peer-to-peer review — a phone conversation between the treating physician and the payer's medical director. This is frequently the last step before a formal appeal, and it's one of the most effective tools for overturning denials.

The problem is that peer-to-peer reviews are scheduled during business hours, often with narrow availability windows. Physicians are seeing patients and can't sit on hold waiting for a payer's medical director. Go Medical Billing manages the entire peer-to-peer coordination process.

We schedule the call at a time that works for your physician, prepare a briefing document with the key clinical points to cover, ensure all supporting documentation is in the payer's system before the call, and follow up afterward to confirm the decision. Our physicians report that having a prepared briefing document reduces peer-to-peer call time from 15 to 20 minutes down to 5 to 8 minutes, with better outcomes because the clinical case is organized and compelling.