Avoid Pre-Authorization Pitfalls Following a few documentation guidelines can help speed approval of your patients’ treatment. On the Pulse
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On the Pulse  |   June 01, 2018
Avoid Pre-Authorization Pitfalls
Author Notes
  • Sarah Hardison, MA, CCC-SLP, is a clinical peer reviewer for eviCore Healthcare in Plainville, Connecticut. sarah.hardison@evicore.com
    Sarah Hardison, MA, CCC-SLP, is a clinical peer reviewer for eviCore Healthcare in Plainville, Connecticut. sarah.hardison@evicore.com×
Article Information
On the Pulse
On the Pulse   |   June 01, 2018
Avoid Pre-Authorization Pitfalls
The ASHA Leader, June 2018, Vol. 23, 38-39. doi:10.1044/leader.OTP.23062018.38
The ASHA Leader, June 2018, Vol. 23, 38-39. doi:10.1044/leader.OTP.23062018.38
“This patient needs services—why were they denied?” the clinician on the other end of the phone asks me. “This patient has a severe language impairment and can’t communicate. How can I get approval for treatment?”
As a speech-language therapy clinical reviewer for a medical utilization management company, I’ve already reviewed the information submitted for this case. I’ve determined that the documentation requirements for this patient were not met, resulting in a denial of services.
“We have reviewed this case, and some required information was not found in your progress report,” I respond.
I explain that some required information—in this case, objective, measurable indicators of the patient’s progress—is not in the documentation. The missing information was readily available—but hadn’t been submitted—leading to this peer-to-peer call.
As a clinical reviewer, I review the documentation that supports requests for services deemed medically necessary. As a certified speech-language pathologist, I know that many of my peers working on the front lines struggle to understand documentation requirements and to submit current information for medical necessity review.
Gathering and submitting the documentation required for prior authorization approval can sometimes be daunting for providers—especially for the clinician treating patients covered by different insurance providers, all of which require prior authorization from different sources.
However, one of the most common reasons for unnecessary denials is missing or inadequate required documentation. For example, a key point that applies to virtually all documentation is that the submitted information must be current, as documentation is time-sensitive. For example, pediatric evaluations are typically considered current if they have been completed within the past year. Submitting an evaluation two or three years old could lead to denial or partial approval of your request. Each insurance carrier has different guidelines and timelines that also may differ depending on the patient’s diagnosis. It’s important to comply with the specific requirements for each patient’s payer.
Although specific expectations differ across insurance carriers, most require the same basic information for clinical review.

One of the most common reasons for unnecessary denials is missing or inadequate required documentation.

Evaluation findings
The provider’s first step should be to verify that the findings from the most recent clinical evaluation are being submitted for review. Even if the patient has been receiving ongoing care and you are submitting a required progress report, it is imperative to verify that the current evaluation findings are on file with the clinical reviewer.
Subjective findings
Submit specific information about how the patient’s condition affects the patient’s quality of life. For example, a patient presents with cognitive decline secondary to a traumatic brain injury. The evaluation reports a formal cognitive assessment showing reasoning skills to be low–average. However, this patient is an engineer with previous reasoning abilities in the 90th percentile, and his goal is to return to work. This type of subjective information can make a significant difference in the clinical review.
Objective measures
A clinical reviewer must be able to compare the patient’s abilities to appropriate norms for the age and condition addressed. This comparison usually includes all applicable standardized evaluations (CELF-5 for pediatric language or BDAE-3 for adult aphasia, for example) and procedures (vocal amplitude and maximum phonation time for voice, for example). These objective measures must correlate with the areas addressed in the plan of care. Assessment guidelines are included in ASHA’s preferred practice patterns document.
Long- and short-term goals: We’ve all heard the acronym SMART, used as a guideline for setting goals. Although there is some variation in the terminology associated with this term, the representation of the concepts is the same:
  • Specific: The goal must clearly identify the objective.

  • Measurable: The goal must include an objective way to evaluate achievement (or lack thereof).

  • Achievable: The goal needs to be scaffolded to be achievable for the patient.

  • Relevant: The goal must be functional for the patient and their caregivers.

  • Time-related: The goal should include a timeline associated with goal achievement.

To indicate the patient’s progress toward long- and short-term goals, use objective, measurable indicators.

Including each of these elements in your goals is essential to providing evidence of patient progress and the benefits of the skilled services you provide.
For example, “The patient will answer ‘wh’ questions” is not a SMART goal. Consider this alternative: “By December 2018, the patient will correctly answer basic ‘what’ questions respondingto highly motivating items and actions presented in the following format: ‘What do you want to (e.g., eat, drink, play, watch)?’ in 4 out of 5 opportunities.”
Your documentation should include the SMART goals as well as baseline and current measures of each goal. You will not receive treatment authorization if you fail to include the current and initial baseline measures used to gauge progress.
Progress reports: To indicate the patient’s progress toward long- and short-term goals, use objective, measurable indicators. Include the baseline or initial measures as well as the patient’s current level. Simply writing progressing, continuing, not met or a similar generic term to specify progress toward a goal is not sufficient information for the basis of a clinical review.
Here is an example of insufficient and sufficient progress resports for the same patient:
  • Insufficient progress report: Patient will categorize 20 functional household items into four categories by June 2018.—Progressing.

  • Appropriate progress report: Patient will categorize 20 functional household items into four categories by June 2018.—Baseline: 25%; current level: 75%.

  • Appropriate progress report: Patient will categorize 20 functional household items into four categories by June 2018.— Baseline: 5/20 items correct; current level: 15/20 items correct.

What do you do if a patient is not progressing as expected toward goals? Include a clear rationale for why. A clinical reviewer will consider special circumstances that contribute to a shortfall in progress, but the reasoning must be specifically documented.
Following these guidelines will help providers and staff avoid some common pre-authorization documentation pitfalls and the treatment delays that can result.
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June 2018
Volume 23, Issue 6