Are you constantly receiving denial code? Time to outsource podiatry medical billing and coding services

Are-you-constantly-receiving-denial-code?-Time-to-outsource-podiatry-medical-billing-and-coding-servicesReceiving denial claims is upsetting for both medical staff and the doctor. It happens often that, that irrespective of how much one takes care of ensuring that everything is in the line and proper there’s still denial codes. When repeated problems occur specifically involving  ICD-9 or CPT codes, instead of looking at the claim denials as a defeat it’s time to come up with a crucial solution. Outsourcing your podiatry medical billing and coding services to a professional company like MBC.

When the healthcare industry is giving so much attention towards patient care, it makes it tough for any podiatry practitioner to keep up with the quality care. Since billing is eating too much of time. Taking time in correcting the errors, training the staff, lead to proper payments, ensure that the documentation is in the line. So, why not get out of these billing stress by involving a professional medical billing and coding partner like MBC to do the backend job?

Here’s why you should:

MBC Billing Expertise

Certified by the American Association of Professional Coders, MBC proficient in using advanced medical billing coding software, the expert at applying standard CPT, HCPCS procedure and supply codes, and ICD-CM diagnosis coding as per CMS guidelines and HIPAA compliant medical coding are fundamentally responsible for optimum medical billing management services to Podiatry physicians.

Zero Mistakes / Errors

Staying ahead of the curve when it comes to changes and updates to medical billing codes and insurance industry regulations and requirements can be a daunting, full-time job.

The regular challenges of managing the billing cycle in-house can drain precious resources from your podiatry practice and distract from care, and the overall patient experience.

Mistakes and oversights in medical coding and on insurance claims can also be costly, and result in delayed or denied claims, and ultimately less revenue. When you have MBC as your medical billing and coding partner, there are 0% chances of such errors and mistakes to happen.

Enabling Accurate Podiatry Billing

MBC being Podiatry billing specialists follows a compliant CPT coding regimen in applying accurate codes for complex services which involves:

  • 76881 for ultrasound, extremity, nonvascular, real-time with image documentation
  • 76882 for the limited ultrasound, extremity, non-vascular, real time with image documentation
  • 93922 for non-invasive physiologic studies of upper or lower extremity arteries, single level as well as bilateral
  • 93926 for the duplex scan of lower extremity arteries or arterial bypass grafts;
  • 20552 for injections, single to multiple trigger point
  • 20553 for injections, single to multiple trigger point
  • 20605 for arthrocentesis, aspiration and/or injections
  • 20610 for arthrocentesis, aspiration and/or injection

Reduce Your Expenditures

MBC’s clients have witnessed reduce in their overall expenditures. All you need is the Internet and a PC. The software comes all-inclusive or you can choose to outsource the entire billing and coding to the team who takes care of your entire practice process.  MBC offers complete billing solutions and practice management needs under one roof.

Closing Thoughts

In order to perform billing and coding tasks for podiatry practices and to receive maximum reimbursement for services provided, it is important to understand the complex rules and guidelines that insurance companies use to judge podiatry claims. Many billing services claim to have this industry insight but often fall short.

For example, medical billing companies that do not specialize in podiatry billing may not have the ability to properly track and pursue underpayments – and this could cost a podiatrist approximately 15% of their income.

In order to avoid billing and coding-related pitfalls such as this one, podiatrists should work with podiatry billing services employing qualified, certified billers. To learn more about MBC and experience working with podiatry practices, contact MBC today.

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How to redefine Podiatry Billing by setting procedural rules?

How-to-redefine-podiatry-billing-by-setting-procedural-rules?

For each podiatry specialization, there is an equivalent specialization in the therapeutic coding and charging rules, directions, and procedures required for that explicit kind of prescription. Podiatry is the same since it likewise requires an exceptional arrangement of therapeutic coding and charging strategies.

Podiatry is the therapeutic strength worried about the determination and treatment of ailments, wounds, and deformities of the human foot. This claim to fame incorporates therapeutic, careful, mechanical, and physical medications of the foot. In that capacity, podiatrist billers are in charge of coding these medications.

Podiatrists treat an exceptionally specific arrangement of indications, infections, and conditions. A portion of these medications are for routine consideration, though others are identified with basic issues, for example, metabolic, neurologic or fringe vascular illness, damage, ulcers, wounds, and contaminations.

CMS, (Centers for Medicare and Medicaid Services), characterizes a considerable lot of the directions with respect to what might be secured benefits under protection. Despite the fact that CMS doesn’t specifically illuminate protection organizations what kinds of administration they could possibly pay for, they do hold influence with regards to podiatry charging and coding rules.

As indicated by CMS, the main secured podiatry administrations are those viewed as restoratively important and sensible foot care. This implies any elective or non-therapeutically essential administrations probably won’t be secured as sensible foot care – protection won’t pay for it!

In the event that the podiatry benefit is for routine consideration, it must be considered. Additional, Mandatory, Supplemental, or Optional Supplemental advantages. Different administrations, similar to the treatment of moles, are secured as it would be as though the moles were situated on some other site on the body (instead of as a particular podiatric benefit).

Certain foot care administrations aren’t secured by Medicare and might be secured under general outsider protection.

In case you’re charging for podiatry administrations, and they fall into these classifications, you might battle a miserable fight against your insurance agency.

They are, with specific exemptions noted:

  1. Routine Foot Care – Some prohibitions to the altogether forswearing of routine foot care administrations include:
  1. Initial care, for an administration that may result in a secured finding
  1. The nearness of a metabolic, neurologic, or fringe vascular malady
  1. Mycotic nails or if the patient is under the consideration of an essential consideration doctor for diabetes mellitus, constant thrombophlebitis, or fringe neuropathies, (for example, carcinoma, lack of healthy sustenance, or various sclerosis)
  1. Flat foot – No exemptions
    Subluxation of the Foot – There are just 2 exemptions to this forswearing: that the         subluxation (or disengagement) was of the lower leg joint or for consideration that       has come about because of the subluxation of structures inside the foot.
  1. Supportive Devices of the Foot – Exceptions incorporate orthotic shoes that are a fundamental piece of a leg prop or helpful shoes for those with diabetes.
  1. Therapeutic Shoes for Individuals with Diabetes – There is 1 exemption to this disavowal, and it incorporates a thin allow of exceptional shoes and embeds for people with diabetes

Just as the run of the mill medicinal coding and charging rules, there are other unique charging rules for podiatry administrations:

Claims including confounded conditions – These have 2 extraordinary necessities:

  1. They must record the name of the doctor who analyzed the entangling condition on the primary accommodation of the case.
  1. They should likewise cautiously record the seriousness of the conclusion, not simply the analysis itself.

The nature of the administration decides the prohibition of foot care, instead of the supplier who plays out the administration. This implies if an essential consideration doctor plays out a non-secured benefit, they won’t be repaid on the grounds that they aren’t a podiatrist. Some installments are made based on being essential to a secured strategy, regardless of whether the coincidental administration is prohibited. These are viewed as an occurrence to administrations.

About Us:

Medical Billers and Coders a Pioneer in the field of podiatry billing and coding channelizing the revenue cycle management and claim procedure.

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How Medical Billers and Coders (MBC) changing the face of General Surgery Medical Billing?

how-medical-billers-and-Coders-mbc-changing-the-face-of-general-surgery-medical-billing

General Surgery, in the midst of forte explicit medical procedures, has not lost its sheen, and general specialists keep on being the particular decision for various surgeries. Doing negligible obtrusive medical procedures (applying creative and progressed Robotic innovation) for more noteworthy productivity, general specialists have been frequently called upon to relocate to more up to date mechanical developments. The recurrence of these mechanical headways has affected the specialists’ time-balance among learning and genuine therapeutic practice. Subsequently, there has been the further unfavorable effect on the acknowledgment of hospital expenses, which – however non-center in nature – is vital to doctors’ sustenance and development.

In any case, still, general specialists, care facilities, symptomatic focuses and healing facilities that benefited master careful charging and coding administrations from us have possessed the capacity to moderate unfortunate situation, and enhance their income age, quiet inflow and referrals, and restorative proficiency.

You can likewise coordinate your prerequisites with the abilities of our master General Surgery billers in your general vicinity.

Navigating the far-reaching space of General Surgery

The use of a magnificent mix of expert magnificence and innovation interface to bill and code assorted general surgeries makes our charging and coding the most looked for after. Following are the assorted surgeries charged and coded under our far-reaching area of General Surgery:

  • Laparoscopic procedures (using automated innovation) on gallbladders, supplements, and colons, and so forth.
  • Trauma surgeries, for example, intubation, burr opening, cricothyroidotomy, and crisis laparotomy or thoracotomy.
  • Colorectal strategies for ulcerative colitis, diverticulitis, colon, and rectal malignancy, gastrointestinal dying, hemorrhoids, and so forth.
  • Breast surgeries, for example, lumpectomy to mastectomy.
  • Vascular surgeries.
  • Endocrine surgeries on thyroid and parathyroid organs.
  • Dermatology strategies, for example, evacuating suspicious moles, an expulsion of greasy tumors, skin uniting, and so forth.
  • Blend of Professional Excellence and Technology Interface.

We have a perfect combination for expert brilliance and innovation interface that has been instrumental in the effective release of medicinal repayment administrations for the general medical procedure.

  • Certified by American Association of Professional Coders (AAPC)
  • Application of trend setting innovation interface:
  • Use of most recent medicinal charging programming projects, for example, Lytec, Medic, Misys, Medisoft, NextGen, IDX, and so forth.
  • Use of most recent coding programming, for example, EncoderPro, FLashcode, and CodeLink.
  • Application of standard CPT, HCPCS system and supply codes, and ICD-9-CM finding coding according to CMS rules – which depict therapeutic, careful, and demonstrative administrations identified with General Surgical administrations – for the effective administration of charging and coding for different General Surgical administrations.
  • A successful reputation of preparing General Surgical bills with the main private protection transporters, for example, United wellbeing, Wellpoint, Aetna, Humana, HCSC, Blue Cross Group, and Government supported Medicare and Medicaid too.

To General Surgery Physicians

The General Surgery Physicians, who loaned inclination to our charging and coding abilities – finish with precise charge-catch, unpredictable technique coding, electronic documenting of cases, tolerant charging, multi-layered intrigue process, forswearing end activities, and consistent models – have possessed the capacity to observe improvement of income cycle, apparent increment in accumulation rates, progressively quiet inflow and referrals, and Increased road for therapeutic innovative work.

Medical Billers and Coders a Pioneer in Medical Billing and coding has channelized the billing of more than 100 surgical centers across the US. The billing company has reduced the typical wait for any claim from 45 days to 15 days and with a reduction of more than 50 percent in claim denials. It’s not just about the claim submission that has reduced the friction between revenue and claims it’s the procedures that been followed by the company to reduce the errors.

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EVALUATING YOUR AMBULANCE TRANSPORTATION MEDICAL BILLING PROCEDURE

 

EVALUATING-YOUR-AMBULANCE-TRANSPORTATION-MEDICAL-BILLING-PROCEDURE Ambulance medical billing has been under the lens of Medicare for a very long time due to the fabrication of medical charges and unreasonable billing rates for the patients during an emergency. In September 2015, a report was released by the Office of Inspector General (OIG) after studying Medicare Part B Ambulance claims. The report clearly stated that almost 20 percent of ambulance providers have inappropriate methods and questionable billing for ambulance transport.

The Medicare is worried if the gaping holes in the system can be identified and used to exploit the opportunity. The OIG identified few key points,

  • Ambulance Transport for beneficiaries that didn’t receive any Medicare at the point of origin and destination.
  • Mileage report has been towards the higher part for the urban areas.
  • Transport levels for the destinations that aren’t covered.

Though each of the points remain to be evaluated based on the patient health, transport facilities available in the region and also demand for specialized care in case of emergency.

Emergency vehicle administrations are secured under Medicare Part B when outfitted to a Medicare recipient under the conditions recorded beneath. Real transportation of the recipient happens. Recipient transported to a suitable destination.

Transportation by Ambulance vehicle must be therapeutically important, i.e., the recipient’s medicinal condition is with the end goal that different types of transportation are restoratively contraindicated. Ambulance Transportation supplier/provider meets all pertinent vehicles, staffing, charging, and revealing prerequisites. The transportation isn’t viewed as a major aspect of a Part An administration.

Ambulance billing companies across the nation need to evaluate their billing procedures before they can control the billing cycles. Below we give you an overview of Ambulance Transportation Billing, 

Claim Data Elements

Type of Bill

You must report the appropriate type of bill. The most common TOBs for ambulance services are:

13X – outpatient hospital

22X – inpatient Part B ancillary (skilled nursing facility)

23X – outpatient skilled nursing facility

85X – outpatient CAH (critical access hospital)

Condition code

Report condition code B2 if you meet the CAH 35 mile run.

Value code/amount

Report value code 32 with the number of patients transported when transporting more than one patient at a time to the same destination.

Report value code A0 along with the zip code identifying the point of pick-up.

Revenue code

Report revenue code 0540 on the claim for ambulance services.

Healthcare Common Procedure Coding System (HCPCS)

HCPCS

                            Definition

A0426 Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1
A0427 Ambulance service, ALS, emergency transport, Level 1
A0428 Ambulance service, Basic Life Support (BLS) non-emergency transport
A0429 Ambulance service, BLS, emergency transport
A0430 Ambulance service, conventional air services, transport, one way, fixed wing
A0431 Ambulance service, conventional air services, transport, one way, rotary wing
A0432 Paramedic Intercept, rural area volunteer ambulance
A0433 Ambulance service, ALS, level 2
A0434 Ambulance service, specialty care transport
A0425 BLS/ALS mileage, per statue mile
A0435 Fixed wing air mileage, per statute mile
A0436 Rotary wing air mileage, per statute mile
A0888 Mileage Beyond the Nearest Facility (noncovered)

Ambulance Modifiers

Report the most appropriate modifier in the claim. Also, the required documentation should be maintained before sending in the claim.

Line item dates of service

You must report the date of service on each revenue code line.

Units

Report 1 unit with HCPCs codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434.

Report the number of loaded miles with HCPCs codes A0425, A0435 or A0436 (mileage must be reported as fractional units). You may round up/down to one decimal place.

The above offers an overview towards the claim filing documentation and requirements that can be evaluated. Each procedure and steps need to be further studied before they can breakdown for the better procedural task for medical billing.

About Us:

Medical Billers and Coders (MBC) a medical billing and coding company have channelized the Ambulance Billing for more than 80 facilities across United States (US).  With trained medical coders and billers we have evaluated the situational medical billing for ambulance transportation that’s causing losses for the facilities.

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Acquaint Yourself with 9 New HCPCS Modifiers

Acquaint-Yourself-with-9-New-HCPCS-ModifiersA modifier is a two-digit numeric or alphanumeric character reported with a HCPCS code, when appropriate. Modifiers are designed to give Medicare and commercial payers additional information needed to process a claim. This includes HCPCS Level I (Physicians’ Current Procedural Terminology [CPT®]) and HCPCS Level II codes. A modifier provides the means by which a physician or facility can indicate or “flag” a service provided to the patient that has been altered by some special circumstance(s), but for which the basic code description itself has not changed.

The 2019 HCPCS Level II code set includes an unusual nine new modifiers that help medical coders and billers accurately report services recently adopted or changed by Medicare. Some are already effective; others are effective January 1, 2019.

Modifiers CO and CQ

Modifiers CO and CQ identify therapy services provided by an occupational therapy assistant (OTA) or physical therapy assistant (PTA).

As described by AAPC Executive Editor Renee Dustman in “Therapy Services Get a Workout in Medicare Final Rule,” these new modifiers are payment modifiers to be used when an OTA or PTA provide more than 10 percent of the service.  The Centers for Medicare & Medicaid Services (CMS) plans to more completely revamp therapy services in the 2020 Medicare Physician Fee Schedule (MPFS).

CO Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant
CQ Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant

 

Modifier ER

Modifier ER is primarily a billing modifier to help identify items and services furnished by an off-campus, provider-based emergency department.

ER Items and services furnished by a provider-based, off-campus emergency department

Modifier G0

Modifier G0 (G zero) is effective beginning January 1, 2019 to identify telehealth services furnished for purposed of diagnosis, evaluation, or treatment of symptoms of an acute stroke.

It’s valid for all of the following:

  • Telehealth distant site codes billed with Place of Service (POS) code 02
  • Telehealth originating site facility fee billed with code Q3014
  • Critical Access hospitals (revenue codes 096X, 097X, or 098X)
 G0 Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke

Modifiers QA, QB, and QR

These oxygen services modifiers were effective April 1 and join existing modifiers QE, QF, and QG. If the prescribed amount of oxygen is less than 1 LPM, suppliers use modifier QA with the stationary oxygen HCPCS Level II code, the monthly payment amount for stationary oxygen is reduced by 50 percent. This modifier is used when the prescribed flow rate is different for nighttime use and daytime use and the average of the two flow rates is used in determining the volume adjustment.

If the prescribed amount of oxygen is greater than 4 LPM and portable oxygen is prescribed, suppliers use modifier QB, with both the stationary and portable oxygen HCPCS Level II code, HHAs use revenue code 0604. If the prescribed flow rate differs between stationary and portable oxygen equipment, the flow rate for the stationary equipment is used. The monthly payment for stationary oxygen is increased by the highest of 50 percent of the monthly stationary payment amount or the fee schedule amount for the portable oxygen add-on. A separate monthly payment is not allowed for the portable equipment if the stationary oxygen fee schedule amount is increased by 50 percent.

If the prescribed amount of oxygen is greater than 4 LPM, suppliers use Modifier QR, HHAs use revenue code 0603. The monthly payment amount for stationary oxygen is increased by 50 percent.

QA Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts is less than 1 liter per minute (lpm)
QB Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts exceeds 4 liters per minute (lpm) and portable oxygen is prescribed
QR Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts is greater than 4 liters per minute (lpm)

Modifier QQ

  • Beginning last July, modifier QQ can be appended for the following situations:
  • When the furnishing professional is aware of the result of the ordering professional’s consultation with a CDSM for that patient
  • On the same claim line as the CPT code for an advanced diagnostic imaging service furnished in an applicable setting and paid for under an applicable payment system
  • On both the facility and professional claim

Check with your payer or consult MM10481 for the codes for which fall within certain ranges.

  QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional

Modifier VM

Part of the Medicare Diabetes Prevention Program (MDPP) expanded the model, this modifier can be added to G9874-G9879 and G9882-G9891 to identify a virtual make up session.

  VM Medicare diabetes prevention program (MDPP) virtual make-up session
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How to Avoid Common Medical Billing Compliance Pitfalls?

How-to-Avoid-Common-Medical-Billing-Compliance-Pitfalls?There are several major issues facing compliance officers today, such as HIPAA, Stark Law, and Anti-kickback Statute issues, as well as many billing compliance issues. Billing issues continue to appear in federal government False Claims Act settlement agreements and government audit reports. Here, we’ll discuss incident-to and shared billing compliance pitfalls and focus on what you can do to fix problem areas.

Incident-to Billing:

The “incident-to” billing rules provide an exception, allowing 100 percent reimbursement for non-physician services that meet the requirements detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60 (Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional Service).

There are six basic requirements to meet the incident-to guidelines for Medicare payment:

  1. The service must take place in a non-institutional setting
  2. A Medicare-credentialed physician must initiate a patient’s care
  3. Subsequent to the initial encounter (during which the physician arrives at a diagnosis and plan of care), an NPP may provide follow-up care
  4. A physician must actively participate in and manage the patient’s course of treatment
  5. Both the credentialed physician and the qualified NPP providing the incident to service must be employed by the group entity billing for the service (if the physician is a sole practitioner, the physician must employ the NPP)
  6. The incident-to service must be the type of service usually performed in the office setting and must be part of the normal course of treatment of a diagnosis or illness

Shared/Split Service:

A split/shared evaluation and management (E/M) visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified non-physician practitioner (NPP) each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service.

The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non-facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to critical care services or procedures. We mentioned common split/shared visit scenarios for better understanding.

Hospital inpatient/outpatient/emergency room setting:

When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or the NPP’s National Provider Identifier(NPI). Example: If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

Office/Clinic setting:

In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician’s NPI. Example: In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the “incident to” requirements are met, the physician reports the service. If the “incident to” requirements are not met, the service must be reported using the NPP’s NPI.

Documentation for split/shared visits should follow the documentation guidelines for any E/M service:

Each physician/NPP should personally document in the medical record his/her portion of the E/M split/shared visit and legibly sign and date the record. The documentation must support the combined service level reported on the claim.

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Prior Authorization and It’s Impact on Practice Collection

Prior-Authorization-and-Its-Impact-on-Practice-Collection

Prior authorization is a check run by some insurance companies or third-party payers before they will agree to cover certain prescribed medications or medical procedures. There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a generic alternative, or checking for drug interactions. A failed authorization can result in a requested service being denied, or an insurance company requiring the patient to go through a separate process known as “step therapy” or “fail first”. Step therapy dictates that a patient must first see unsuccessful results from a medication or service preferred by the insurance provider, typically considered either more cost-effective or safer before the insurance company will cover a different service.

Prior authorization is a headache for patients and providers. It’s a time-consuming process: physician offices spend hours getting OKs from health plans to cover medications and specific medical procedures. The idea behind prior authorizations is cost savings. Getting authorization beforehand should ensure only appropriate procedures and medications are provided to patients.

A recent study in the “Journal of the American Board of Family Medicine” estimated that the mean cost per full-time provider for prior authorization compliance was between $2,100 and $3,400. Keep in mind, this figure accounts only for the provider’s time, not including the time of other credentialed staff and front office employees. In 2017, the most recent year comprehensive figures were compiled, the average primary care nurse spent 14.1 hours per week on the patient prior authorizations and clerical staff spent 6.4 hours per week on prior authorization-related tasks.

Altogether, according to research published by “Health Affairs,” the annual cost of compliance with insurance-mandated prior authorizations is between $23 billion and $31 billion per year. It doesn’t take a CPA to tell you that keeping up with the never-ending prior authorization paperwork is a drain on your practice’s profit.

According to research from the American Medical Association, who analyzed a large number of claims for their 2013 National Health Insurer’s Report Card, not all payers are equal in their prior authorization burdens. Check out these statistics about the percentage of claims requiring  prior authorization:

Year  Aetna  Anthem  Cigna  HCSC  Humana  UHC Medicare 
2012 4.70% 2.20% 7.10% 4.10% 14% 6.70% 0.80%
2013 5.40% 2.10% 4.70% 7.30% 8.40% 12.40% 3.50%

Most prior authorizations involve imaging studies and medications, and the Government Accounting Office reports spending on advanced imaging studies has increased at a much more rapid rate than less expensive studies, which may be driving some of the increase in prior authorizations. On the other hand, the wider availability of inexpensive generic drugs reducing some of the paperwork burdens for medications.

Prior authorization is an unavoidable cost of running a medical practice, but there are some steps you can take to lower the drain on staff hours.

  1. Centralize the prior authorization process with just one or two staff members. This streamlines the procedure and facilitates forming personal relationships with major payers, making things move more quickly and easily.
  2. Familiarize yourself with your main plan formularies and develop treatment protocols around medications covered by the plan that doesn’t require prior authorization for the conditions you treat most, provided it’s medically appropriate for the patient.
  3. Use your EHR to capture demographic information and progress notes supporting medical necessity for use when a payer’s utilization review department will need it for prior authorization for advanced imaging studies and other procedures. Be sure you know the authorization criteria for each payer so your EHR form captures everything that will be required to get the approval.
  4. Evaluate your insurance contracts to see which payers require the most prior authorizations. If it’s a contract that isn’t a major part of your revenue, and it’s taking an inordinate amount of time in compliance, consider whether you really want to participate when it’s time to renew.
  5. Use the payer’s website whenever possible to get authorization; phone service takes much longer.
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