Pended authorizations and the follow-up discipline

2 min read

Ask a practice about authorization denials and you will hear about clinical disagreements with reviewers. Look at what actually caused rescheduled procedures and the leading cause is different: a request that pended, was not chased, and arrived at the service date undecided. Nobody denied it. Nobody decided it.

#Why pends go stale

• The submission left the practice system, through a portal or a fax, so nothing tracks it.
• It is tracked in a spreadsheet owned by one person, and that person was away.
• The payer requested records and the request went to a fax queue nobody monitors.
• Everyone assumed it was fine because no denial arrived. Silence reads as progress.

#A follow-up cadence that works

Constant polling annoys the payer and wastes staff time. Never polling loses cases. The workable pattern is a cadence that tightens as the service date approaches:

1. Early
   Check infrequently. The payer has a decision window and calling on day two rarely changes anything. Record that you checked.
2. Middle
   Increase frequency. If the plan has a regulatory or contractual decision deadline, know what it is and when it falls.
3. Approaching the service date
   Daily, and escalate. This is where a call has value, because you can ask specifically which stage it is in and whether anything is outstanding from you.
4. Deadline passed
   A decision timeline that has lapsed is a different conversation. On a plan subject to a statutory or CMS timeline, cite it. This is why knowing the regulator matters; see Who regulates your payer.

#The question to ask

Not "has it been decided", which gets "it is still in review". Ask which stage it is in and whether anything is outstanding from the practice. Those two questions distinguish a request waiting on records you could send today from one sitting in a physician queue where nothing you do will speed it up.

#What to do when the date arrives undecided

This is a clinical and financial decision, not an administrative one, and it belongs with the physician and the patient rather than with the authorization team. Proceeding without authorization risks the claim. Rescheduling has a clinical cost that varies enormously by case. Some plans permit retrospective review in defined circumstances, which is worth knowing in advance rather than discovering under pressure.

What is not acceptable is that the choice arrives as a surprise on the day. A follow-up discipline that surfaces at-risk cases while there is still time to act is the entire point.