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Reductions in Prior Authorization Requirements Don’t Necessarily Equate to More Revenue
August 8, 2023
Considerations for Laboratories, Radiology Practices, DME, Medical Device, and Independent Diagnostic Testing Facilities (IDTFs)
There has been a lot of industry talk and media coverage lately around efforts by states (through “Gold Card” laws and programs) and payors to reduce the volume of prior authorization (PA) requirements. UnitedHealthcare (UHC) is one of the latest to announce the elimination of PA requirements for many procedure codes.
UHC’s announcement states:
“To help reduce the administrative burden on health care professionals and their staff, starting September 1, 2023, we’ll begin a two-phased approach to eliminate the prior authorization requirement for many procedure codes. Together, these code removals account for nearly 20% of UnitedHealthcare’s overall prior authorization volume.”
Find UHC’s list of impacted codes here.
On the surface, this is certainly good news for patients who will no longer have to wait on PAs to receive vital diagnostics and therapeutics. That said, it’s important for laboratories, radiology practices, medical device, DME, IDTFs, and other diagnostic providers to recognize that eliminating PA requirements for certain procedure codes does not eliminate the potential for denials. In other words, eliminating PA requirements will not automatically translate into an increase in revenue.
It is important for diagnostic providers to monitor denial codes for medical necessity and requests for medical history and documentation to understand the true revenue impact associated with these changes.
The following are the Claim Adjustment Reason Codes and Remittance Advice Remark Codes that providers are currently receiving associated with a lack of prior authorization:
243 – Services not authorized by network/primary care provider
288 – Referral absent
M62 – Missing/incomplete/invalid treatment authorization code
N475 – Missing completed referral form
N476 – Incomplete/invalid completed referral form
N489 – Missing referral form
N490 – Incomplete/invalid referral form
50 – These are non-covered services, deemed as not a ‘medical necessity’ by the payer
55 – Procedure/treatment/drug is deemed experimental/investigational by the payer
56 – Procedure/treatment has not been deemed ‘proven to be effective’ by the payer
96 – Non-covered charge(s)
204 – Service/equipment/drug is not covered under the patient’s current benefit plan
252 – An attachment/other documentation is required to adjudicate this claim/service
272 – Coverage/program guidelines were not met
M30 – Missing pathology report
M31 – Missing radiology report
M60 – Missing certificate of medical necessity
M127 – Missing patient medical record for this service
M135 – Missing/incomplete/invalid plan of treatment
N181 – Additional information is required from another provider involved in this service
N237 – Incomplete/invalid patient medical record for this service
N393 – Missing progress notes/report
N394 – Incomplete/invalid progress notes/report
N395 – Missing laboratory report
N396 – Incomplete/invalid laboratory report
N457 – Missing diagnostic report
N458 – Incomplete/invalid diagnostic report
N463 – Missing support data for claim
N464 – Incomplete/invalid support data for claim
N705 – Incomplete/invalid documentation
N706 – Missing documentation
N709 – Incomplete/invalid notes
N710 – Missing notes
N888 – An electronic request for additional information has been sent for this claim
We encourage our customers to monitor for changes in denial trends related to these codes as PA requirements are lifted. The relief of burden on the front end of the process may result in increased time spent on appeals, impacting the cost to collect, extending days in AR, and adding demand onto resources on the back end of the process. Rest assured that if your organization does see an uptick in denials, XiFin’s strategic approach to appeal automation will help maximize appeal success.
Here at XiFin, we support streamlining the RCM process and improving the experience for our customers, their clients, and patients. We support eliminating PA requirements where it makes sense. We empower our customers to monitor their data to recognize the full impact of these changes and whether they may create unexpected impacts for laboratories, radiology practices, Medical Device, DME, IDTFs, and other diagnostic practitioners.