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Improving Your Prior Authorization Process


Improving Your Prior Authorization Process

Many providers are not fond of the growing number of prior authorizations needed by insurance companies in recent years. A 2019 study from the American Medical Association reported that 86 percent of providers believe that prior authorizations have increased in the last five years. Providers believe that prior authorizations are time-consuming and detract from time spent with patients. Some go as far as to believe that prior authorizations are purposefully put in place to be burdensome so that providers or patients will simply give up and use a cheaper alternative. Providers do not appreciate spending time to undertake administrative tasks like completing prior authorizations when they are not properly reimbursed for the time spent or when they do not have trained staff to expedite the process. In a 2016 study by the Annals of Internal Medicine, it was reported that for every hour a physician spends with a patient, they have to spend an additional 2 hours on desk work. Whether you like it or not prior authorization ensures that your every claim will get paid so you should implement all your resources on improving your prior authorization process.

What is Prior Authorization?

Prior authorization (PA) is defined as approval from a health plan that may be required before a patient gets a service or fill a prescription in order for the service or prescription to be covered by an insurance plan. The prior authorization process has many names including precertification, pre-authorization, prior approval, and predetermination. Services like medications, imaging studies, etc. that require prior authorizations need healthcare providers to obtain approval from the patients’ health insurance. The process is long and can often delay patients from receiving the care they need.

Improving Your Prior Authorization

For improving the prior authorization process, providers and healthcare organizations can standardize certain steps. Providers should always keep up with the ever-changing clinical guidelines on every disease state since insurance companies also update the need for prior authorizations based on these guidelines. Ordering prescriptions outside of normal practice often results in the need to submit a prior authorization to the patient’s plan. It can also be beneficial to create lists of medications and procedures that are covered by each plan. Furthermore, these lists can be incorporated into the electronic health record to alert physicians when they order something that requires prior authorization. Being familiar and keeping up to date with insurers’ policies and formularies can reduce the patient's delay of care.

Eligibility and benefits verification: Eligibility verification is much more than merely collecting and recording the right insurance information. Enhancing the eligibility process means digging deeper to discover whether the patient has met the plan deductible, whether the plan requires a referral for service, and whether their plan will cover the scheduled procedure, and at what percentage. You must take a more in-depth look into eligibility verification both before treatment and after a claim has been denied. If your processes have gaps, money is being unnecessarily lost.

Identify payer: Beyond plan coverage, specialist providers should be aware of payer guidelines. Consider an example, the insurance provider may not always cover a skin lesion’s removal if the treatment does not fall under a specific diagnosis code, or if the visit falls under a particular scope of care. In this example, the physician would need to know in advance that the insurance provider will not authorize payment for the service and should have a strategy in place for identifying the patient as the payer. If a practice frequently deals with out-of-network plans, this strategy is even more crucial. Administrators need to do everything in their power to collect from the right payer, whether that be an insurance provider or the patient themself, especially if you want to make out-of-network services worth the cost.

Have checklist: For every patient and for every visit you must have a checklist. You must have questions each time you determine a patient’s eligibility: Does this patient need prior authorization? Has the necessary approval been acquired? Has the patient reached the deductible limit? Do you know the particular CPT codes and modifiers? Have you reviewed specific or specialty coverage rules?

Verify patient responsibility: When you are calling for eligibility and benefits verification check if: whether the deductible has been met; specific coverage rules; whether the procedure is covered; how the plan handles procedures. Verifying this information ahead of time helps set a standard with your patients so they know what to expect from your office. It may seem tedious, but your due diligence to ensure eligibility for every procedure, no matter the value, will result in higher reimbursement rates across the board.

Be prepared before the patient arrives for visit: Before a patient arrives at the office, you must have details like the patient’s insurance policy (primary as well as secondary), policy coverage for the service or treatment the patient intends to receive/ eligibility, and benefits report, patient responsibility, any information needed by the payer to get the claim paid.

Have trained staff: Assign and training certain members of the staff to handle prior authorizations requests may be beneficial to reduce time physicians spend on the phone with insurers. These designated staff members will become more knowledgeable and efficient in handling prior authorizations over time. There are great benefits to having a prior authorization certified specialist on staff to help with the administrative process. The prior authorization process can be navigated easily and efficiently with the right resources and staff to help in the process. Trained professionals can make the process seamless, especially when the document and maintain records.

Documentation is key: It is important to have good documentation policies. If a prior authorization requires step therapy in its criteria, each trial will need to be documented. Having documentation of all prior attempts will help expedite the approval process. Long-term record-keeping of prior authorization submissions can make reauthorization easier as well.

Prior authorization plays an important role in revenue cycle management, it ensures that every single patient visit will get paid either from the payer or from the patient. We hope that the above-mentioned steps will help you in streaming your eligibility and benefits verification process and will eventually help in improving your prior authorization process. In case if you don’t have trained staff or sufficient time to handle prior authorizations, you can take assistance from medical billing company like us. If you need any assistance in medical billing and coding services or just eligibility and benefits verification services, contact us at info@medicalbillersandcoders.com / 888-357-3226

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