Preauthorization Inconsistencies Prevail in Reduction Mammaplasty.

Background: Despite evidence documenting the physical and psychological benefits of breast reduction, third-party payer approval remains a cumbersome process. The objective of this study was to assess differences in medical necessity criteria for reduction mammaplasty among US insurance carriers while analyzing trends in claim denials and appeals. Methods: The medical necessity criteria for reduction mammaplasty were retrieved from seven large health insurance carriers. Data were extracted from each policy, including claim requirements for approval. Additionally, prospective data on claims and denials submitted from January through August 2022 were collected from The Auctus Group, a medical consulting firm. Results: All the policies have been updated since January 2020. Five of the seven policies specifically listed what documentation was required for preauthorization approval, with five third-party payers requiring photograph documentation. Policies required documentation of one to three symptoms lasting from 6 weeks to 1 year. All companies reported a tissue resection estimate threshold, but cutoffs varied. Of 380 reduction mammaplasties performed, 158 (41.6%) received a denial on initial insurance submission. Considering appeals, a total of 216 denials were reviewed with an average of 1.37 denials per patient. Of the 158 initial denials, 104 (65.8%) of these were from claims that received preauthorization. In 12 cases, third-party payers stated that no prior authorization was necessary yet still denied the claim. Conclusions: Wide variability exists in medical necessity criteria for reduction mammaplasty policies among major insurance carriers. These nuances introduce inefficiencies for practices contributing to high denial and appeal rates while delaying surgical care for patients.

Staffing snafus driving surgeons over the edge.

Staff expenses range from 23% to 34% of a practice's total revenue according to recent Medical Group Management Association surveys, making salaries one of the biggest expense categories. As a result, physicians and senior practice managers must assess the competency of employees, implement stepped-up training programs to meet the technology and reimbursement training needs of today, and institute more sophisticated hiring assessments and background checks before hiring new or replacement staff.

Why your practice must do background checks.

Hiring qualified staff is critical for a medical practice. As many physicians have discovered, taking applicants' resumes on faith can be a mistake. Background company searches show that one in three applicants provide false, inaccurate, misleading, or incomplete information. Fake degrees, false licenses and certifications, and criminal histories are a few of the problems that a proper background check can reveal. This article describes further why background checks are essential, how to incorporate a background check into your hiring process, and some of the legalities involved in the process.

Avoiding leasing pitfalls.

Even though most physicians will only negotiate a few leases during their careers, it pays to be proficient in the language of leasing. Understanding a few key terms and concepts up front will prevent unnecessary hassles and unexpected expense. This article explains some of the most common misunderstandings in the leasing process, such as types of leases, rentable vs. usable space, escalations, and other considerations. Physicians will benefit from these practical suggestions by learning what questions to ask before signing a lease.