An approval isn’t finished until everyone receives it

We once saw a patient scheduled for imaging at an outside facility have their appointment canceled even though the prior authorization had already been approved.

The imaging facility did exactly what it was supposed to do. During its last-minute checks, the staff couldn't find any evidence that the procedure had been authorized. The provider's office hadn't sent the approval over, so the facility canceled the patient, went back and forth with the provider's office to get the information, and then had to reschedule the appointment.

Outside facilities make a point to check for prior authorization because it protects their revenue. If they perform a procedure without the correct authorization, they risk not being paid for it. An authorization sitting in someone else's EHR or payer portal doesn't give them enough confidence to proceed.

The rule should be simple: before an authorization is finished, it must reach everyone relying on it to continue their part of the process. At a minimum, that means anyone whose revenue depends on the authorization.

The authorization has to reach the right people

Ideally, the ordering provider, rendering provider, and facility should all receive the result. If the ordering and rendering providers are different and you had to choose only one, the rendering provider is probably the most important. They're the one risking not being compensated for the service.

The same problem exists outside of imaging. I've sat with people who work at surgery centers, and a significant part of scheduling a surgery is making sure all the authorization information is on file. If it wasn't communicated to them, they have to stop and try to find it. That wastes their time, creates unnecessary back-and-forth, and can ultimately delay the procedure.

At a bare minimum, the recipient should get:

• The authorization number
• The authorized procedure
• The effective date range

Supporting documentation is even better. A printout from the payer portal gives the facility more confidence in the result and reduces the chance that a typo was introduced when someone copied the authorization number or dates into another system.

Even then, payer communications aren't always reliable. Sometimes an authorization number becomes visible before the full determination can be opened in the portal. Sometimes the payer's fax doesn't come through, or it reaches the wrong person. Those problems are inevitable, which is why the provider's process can't depend on a single payer notification reaching the right place.

Why the handoff gets missed

The handoff fails because it's an extra step after work that already feels finished.

Once an authorization is approved, someone usually has to enter the result into the EHR. Then they have to communicate it to somebody else. That might involve printing the determination and walking it over to a physical fax machine. If the office uses electronic faxing, it may require saving the result as a file, opening another system, uploading the file, finding the right fax number, and sending it.

It's tedious at best, and there are a lot of places for mistakes to slip through the cracks. The person doing the authorization might assume the payer will fax the facility. The facility might assume the provider's office will send it. Everyone has a reasonable explanation, but the patient still gets canceled.

In a manual process, the person completing the prior authorization should be responsible for communicating the result. If your practice uses a prior authorization checklist, which I highly recommend, sending the result should be one of the final steps before the case can be closed.

What to check before closing the case

Before sending the approval, staff should verify that it matches what was actually ordered. That includes:

• The procedure code, laterality, quantity, and body part
• The diagnosis
• The ordering provider
• The rendering provider
• The facility
• The addresses and contact information for everyone involved

From there, the right communication method depends on the case.

If a medical assistant completed an authorization for a procedure the same doctor will render in the office, recording it in the EHR and closing the corresponding task may be enough. Everyone involved is working within the same system.

The most complex case is a provider referring the patient elsewhere, with a different rendering provider and facility. Fax is old-school, but every practice worth its salt has one. It's also asynchronous. The recipient doesn't have to stop whatever they're doing at the exact moment the result arrives, and the sender doesn't have to wait for someone to answer the phone.

A HIPAA-compliant email can provide another channel. Within an integrated health system, that might instead be an EHR task, internal chat, or another organizationally approved method of communication. For a time-sensitive STAT case, the phone is still the best option. It should be used judiciously because it pulls someone out of their work, but sometimes that interruption is exactly the point.

For outside referrals, sending the result through at least two appropriate channels gives the case another chance to keep moving if one message gets lost or missed.

How Davner closes the loop

The moment Davner becomes aware of an approval, we first compare it with what was ordered and check for mistakes. When our AI reads the result from a payer portal, it pulls the information directly rather than asking someone to retype the authorization number and dates. That eliminates an entire category of transcription errors.

From there, Davner emails the staff member who initiated the request to let them know the case has been updated. We also automatically fax the ordering provider, rendering provider, and facility when a fax number is on file. If two of those parties share the same fax number, we don't send the same fax twice.

The fax contains the authorization number, dates, service, procedure codes, providers, facility, and the other information the recipient needs to act on the result. The practice can see the full history afterward in the Davner portal, including who was notified.

The next time an authorization is approved, make sure it gets to the right people as quickly as possible. No patient should have to be delayed or canceled, and no provider should lose revenue, just because an approval stopped one step short of the finish line.