Referrals and Prior Authorizations by Fax

Of everything a medical practice faxes, referrals and prior authorizations matter most to patients. A referral that stalls delays a consultation. An authorization that waits in a tray can delay a procedure, a scan or a prescription. Both are requests that need an answer from another organization, and in both cases the fax itself is only the first step of the work.

This article follows each kind of request from the moment it is sent to the moment it is answered, identifies where they usually stall, and sets out a simple way to track every one.

The life of a referral

A referral by fax has more steps than it first appears, and each one can go quiet.

1. Sent. The referring office faxes the referral form, with the clinical information the specialist needs.
2. Received. The specialist's office receives it, and someone has to notice it and match it to a patient.
3. Accepted or questioned. The specialist's office accepts the referral, or asks for more information.
4. Scheduled. The patient is contacted and an appointment is booked.
5. Closed. After the visit, a consult note goes back to the referring provider, often by fax.

The most common stalls are at step two, where a fax sits unnoticed, and at step five, where the loop is never closed and the referring provider does not learn what happened.

What a referral needs to contain

Disclosures between providers for treatment are an exception to HIPAA's minimum necessary standard, which is set out in 45 CFR 164.502(b). That does not mean a referral should include the whole chart. A focused packet, with the reason for referral, relevant history, recent results and insurance details, is faster for the receiving office to process and less harmful if it goes astray.

The life of a prior authorization

A prior authorization follows a similar pattern, with the payer in the middle.

1. Requested. The practice submits the request and supporting clinical documentation.
2. Pended or questioned. The payer may ask for more information, often by fax.
3. Decided. The payer approves, partially approves or denies the request.
4. Acted on. The practice schedules the service, or prepares an appeal or a peer to peer review.

Unlike a referral, a request to a payer is for payment rather than treatment, so the minimum necessary standard applies: send what the payer's criteria ask for, not everything available.

What is changing in prior authorization

The Centers for Medicare and Medicaid Services' final rule on Advancing Interoperability and Improving Prior Authorization Processes (CMS-0057-F) requires impacted payers to support electronic prior authorization through application programming interfaces, and finalizes decision timeframes of 7 calendar days for standard requests and 72 hours for expedited requests for those payers. The rule applies to specific payer types, and its discussion acknowledges that provider adoption of electronic prior authorization will be gradual. Faxed requests, and faxed requests for more information, will remain part of most practices' work for some time. Our article on why healthcare still runs on fax covers the wider picture.

Where requests stall

Across both workflows, the same few problems account for most delays:

• Unnoticed arrivals. A request for more information from a payer, or a question from a specialist's office, arrives on a busy shared number and waits.
• No owner. Nobody is responsible for following up, so a request that received no answer is not chased.
• No proof of sending. When the other side says nothing arrived, the practice cannot show what was sent and when.
• Incomplete packets. A missing page or result triggers a request for more information and a second round trip.

Track every request from sent to answered

A tracking log does not have to be sophisticated. A shared spreadsheet or your practice management system's referral and authorization module will do, as long as it records the same fields every time:

• an internal reference number;
• the patient, the service and the other party;
• the date sent and the delivery confirmation;
• the follow-up date;
• the current status: sent, questioned, accepted, scheduled, decided, closed; and
• the person responsible.

Two habits make the log work. First, set the follow-up date at the moment of sending, not later. Second, review open items daily, oldest first. Our guide to naming, filing and tracking faxed documents explains how to tie each log entry to the transmission record and the filed document.

Route the replies, not just the requests

Practices often organize outgoing referrals and authorizations carefully and leave the replies to land wherever they land. Give replies a route too. A dedicated number for referral and authorization correspondence, delivered to the coordinators who own the log, means questions and decisions reach the person who can act on them. Our article on routing incoming faxes to the right team explains how to set that up and publish the number to the offices and payers you work with.

Close the loop

For referrals, the last step is the one most often skipped. When a consult note arrives back, file it to the chart, mark the referral closed in the log and make sure the referring provider sees it. For authorizations, record the decision, notify the scheduling team and keep the decision letter with the request. A closed loop is what turns a fax workflow into a record of care rather than a pile of transmissions.

Where LABUSA eFaaS fits

LABUSA eFaaS delivers incoming faxes as digital documents to the recipients you designate, so referral and authorization correspondence can go straight to the coordinators who own it. Outgoing faxes are sent from email, and every transmission leaves a queryable record with status and delivery confirmation, which answers the question of what was sent and when. LABUSA can also design custom workflow rules that route incoming referrals to designated staff and notify the right people; that automation is scoped after a requirements assessment and delivered separately from the standard fax service.

See how this fits a medical office on our medical practices page, read how eFaaS works, try LABUSA eFaaS free for 30 days, or request a workflow consultation. You can also contact our team.