Prior Authorization Calls for Surgical Procedures

Absorbs the status calls that surround every pending case, answering only from what your record shows and never implying an approval, a denial or a date that your team has not recorded
Captures anything that changes the request, including a different planned approach, a different facility or a moved date, and flags it so your team can decide whether the existing authorization still covers the case
Recognises that plan type changes the work: most Medicare Advantage plans require prior authorization for some services, while traditional Medicare generally does not
Handles site-of-service questions, since where a case is performed can change what is required, and Medicare rules already require prior authorization for certain hospital outpatient department services including panniculectomy
Cost and deductible questions arriving on the same call are routed to your financial counsellor with the case details attached, and are never answered with a number the system estimated
Payer callbacks, peer-to-peer requests and denial notifications route immediately to the person your protocol names, with the caller, plan and reference number captured accurately the first time

How it pays back

The Status Calls Are the Volume

Submitting an authorization is a task. Being asked about it is a workload. A patient waiting on approval for a hernia repair may call weekly, and each of those calls interrupts the one person holding the surgical calendar. Answering them consistently, from your record, is where the time is recovered.

An Authorization Is Attached to a Plan, Not a Patient

Approval is issued against a specific procedure, surgeon, facility and window. When any of those change, and in surgical scheduling they change often, the safe assumption is that your team needs to look again. The system's job is to notice the change and surface it, not to decide the approval still holds.

Peer-to-Peer and Denials Belong to Your Team

A payer's medical reviewer calling for a peer-to-peer conversation needs a physician, immediately, not a message. Those calls route on the path you define. Nothing is negotiated, no clinical rationale is offered, and no coverage determination is ever characterised by the system.

The Financial Question Rides Along

Patients rarely ask only whether surgery is approved. They ask what it will cost, whether the assistant is in network, and whether the facility bills separately. Those questions are captured with the case and routed to the person who can answer them properly, rather than guessed at on the phone.

Status answered from your record

Never from an assumption, and never with an approval the system inferred

Exceptions routed immediately

Peer-to-peer requests and payer callbacks reach the person your protocol names

Encrypted end to end

Plan, policy and case data protected with AES-256 at rest and TLS in transit, under a HIPAA BAA

Frequently asked questions

Does the system submit authorizations to payers?

No. It works the telephone and coordination load around them: patient status calls, captured changes to the case, payer callbacks and routing. Submission, clinical documentation and appeals stay with your authorization staff, where the accountability belongs.

Can it tell a patient their surgery has been approved?

Only when your record says so and your rules permit reading it back. Otherwise it captures the question and routes it. A wrongly confirmed approval sends a patient into a pre-op pathway and creates a bill nobody agreed to, so the default is to say what is known and no more.

How does it handle a denial?

It never states a denial or explains a reason for one. A payer communication is captured and routed to your team, and a patient asking about a denial is handed to the staff member your protocol names, because that conversation usually needs a clinical or appeals decision behind it.

Does the plan type actually change the workflow?

It changes what to expect. Most Medicare Advantage plans require prior authorization for some services while traditional Medicare generally does not, and commercial plans differ case by case. The system captures the plan accurately so your staff apply the right pathway rather than discovering it late.

Does site of service matter for authorization?

It can. Medicare already requires prior authorization for certain hospital outpatient department services, panniculectomy among them, and CMS has introduced a demonstration extending prior authorization to the same service categories in ambulatory surgery centres in a set of states. Where a case is performed is worth capturing.

Can it quote what the patient will owe?

No. It does not quote benefits, estimate patient responsibility or interpret a deductible. Those calls are captured with the case detail and routed to your financial counsellor, which is both safer and faster than a number the patient will hold you to.

Authorization Status Calls That Stall the Surgery Date