Aug 16, 2024
Apr 3, 2025
Written By Elizabeth Cifers
Denials on drug claims after prior authorization are frustrating and result in reimbursement loss because the injection has occurred, and the drug invoice still must be paid. To avoid this unfortunate scenario, it may be helpful to understand better why denials—despite prior authorization—typically happen. Here are three reasons your retina practice may be denied drug reimbursement although you received prior authorization:
1. The physician switched drugs without clearly documenting a medical reason. The documentation should show a traceable “bouncing ball” of medical reason(s) for switching drugs. If it does not, the claim is likely to be denied.
2. Payer step therapy (try-and-fail) criteria were not met. Many Medicare Advantage and commercial payers require step therapy, or try-and-fail, in addition to prior authorization. If payer requirements are not followed, the drug will most likely not be reimbursed.
3. The diagnosis was off-label for the drug. Using a drug for a non-FDA-approved reason puts reimbursement at risk. Additionally, payers may only include some of the diagnosis codes considered on-label in their policy. Thus, a payer may deny a claim for an off-label diagnosis.
If your retina practice is being denied drug claims after prior authorization, you’re not alone. While denials are a pain—especially in the context of prior authorization—they can sometimes be avoided. Ensuring proper documentation and following payer requirements will help, plus—these factors are under your control.
Consider hiring a documentation, coding, and billing consultant. Consultant Elizabeth Cifers has decades of industry expertise and a knack for untangling reimbursement hang-ups and the challenges that contribute to them. She excels at maximizing revenue in retina. Schedule a free consultation here.
.png)
