A medical assistant is preparing a referral for a 58 year old patient with a six month history of worsening exertional dyspnoea whom the family physician has just referred to cardiology for an outpatient stress echocardiogram in four weeks. The patient has commercial insurance that requires pre-authorisation for advanced cardiac imaging. What is the BEST next action before the patient leaves the clinic?
- ASubmit the pre-authorisation request to the insurer with the diagnosis code, requested CPT code, and supporting clinical notes, then schedule the cardiology appointment once approval is received. Correct
- BHand the patient the cardiology contact details and tell them to ring the insurer themselves to obtain the pre-authorisation before the appointment.
- CSchedule the stress echocardiogram immediately and submit the pre-authorisation request to the insurer on the morning of the procedure to avoid delay.
- DSend the cardiology office a one line note stating the patient needs a stress echocardiogram and let the specialist handle authorisation and records.
Why A is correct: Commercial payers require pre-authorisation to be obtained before a non-urgent specialty imaging study is performed; submitting the request with diagnosis, procedure code, and clinical justification, then booking on approval, protects the patient from a denied claim and ensures continuity of care.
Why B is wrong: It is tempting because the patient is ultimately the policy holder, but offloading the pre-authorisation to the patient is outside accepted referral workflow and routinely leads to denied claims and missed appointments; the referring practice initiates the authorisation.
Why C is wrong: This sounds efficient because it locks in a slot quickly, but submitting authorisation on the day of a non-urgent study risks the insurer denying the claim, leaving the patient or practice liable for the cost.
Why D is wrong: It feels reasonable because the specialist performs the study, yet a complete referral must include reason, urgency, relevant history, and attached records; a bare request leaves the receiving office without the information needed to triage or to support authorisation.