Prior authorization (PA) requires a pharmacy to obtain approval from your health insurer to dispense a specific medication prescribed by the doctor to you. The PA clause is usually put to use in case for very expensive medication. The adoption of PA technique is known to minimize health care costs, as the benefits are only paid if the medical care has been pre-approved by the insurance company. In the absence of Prior Authorization, your insurance plan may not pay for the medication prescribed to you. To allow proper practice management with effective prior authorization services can require a critical pharmacy management strategy.
Prior authorization can be important in cases of certain drugs as :
– A drug may have dangerous side effects or can be harmful when combined with other drugs.
– A drug has limited usage for certain health conditions.
– The drugs are often misused or abused.
– Drugs not usually covered by the insurance company, but said to be medically necessary by the prescriber. Many different drugs can be used to treat the same condition. If a patient requires a particular medicine, the doctor must inform the insurance company that there are no other medicines that would be effective for the patient.
Reasons Why Prior Authorization May Not Be Approved
In general circumstances, an authorization number is assigned by the Payer prior to the service. Pharmacies need to include this pre-assigned authorization number on the claim when you submit it for payment. It is a well-established fact that prior authorization is a manual procedure which needs extensive scrutiny. Quality Prior Authorization management requires the Pharmacy staff to be well versed at understanding healthcare credentialing and adjudication process. Here are some reasons why Prior Authorization may not be approved:
- Insurance company, doctor or the pharmacist did not get enough time to complete the needed steps. It can take several business days for the insurance company to respond.
- Physician’s office neglected to contact the associated insurance company.
- Pharmacy is not billing your insurance company properly. Sometimes billing for a medicine that needs a PA requires a special billing code. The pharmacy could also have received an incorrect PA code.
- Sometimes, even if the drug is approved, the approval may only be valid for a limited time, such as for one year, and sometimes for only a month. After that, the process must be revised.
Specialized billing companies can help pharmacies be more patient centric while dealing with Prior Authorization. Competent understanding of the health care administration process gives Pharmacy Billing Specialists an edge to serve pharmacies better and to provide affordable billing solutions. Outsourced prior authorization personnel submit planned, succinct, and well-articulated application with supporting clinical information. Eliminating errors and submit clean claims, which are quickly processed and reimbursed the very first time they are submitted to the Payers, help to overcome the need for conventional in-house staffing.
A transparent strategy for prior authorization services is a must for the providers to survive fierce competition. New Age technology helps in streamlining the entire management process and claim filing which begins at the right verification of benefits to patient demographics that reduces time & increases ROI.
A renowned pharmacy billing outsourcing partner in healthcare works with a number of insurance companies assisting them in their claims adjudication process. Thus they have expertise to handle verification process, while keeping alignment to an individual payer’s requirements contributing to a better denial management system.
Why Do You Need to Outsource Pharmacy Billing for Stronger Prior Authorization?
A transparent strategy for prior authorization services is a must for the providers to survive fierce competition. To bring true excellence in the claims submission process, in-depth competence is desirable to enhance the revenue cycle. Partnering with a billing specialist that pledges to transform billing with effective practice management guarantees consistency in Return On Investment. Here are the sections where the right vendor might help you in Pharmacy Billing:
Lack of Vision and Growth Plan: In absence of the right road map towards growth with effective scrutiny and verification services the results can be catastrophic for a provider. It hampers the growth & ROI of a pharmacy.
Absence of Technical Acumen: It is mandatory that the pharmacy staff understands each individual patient’s benefits-verification and updates the information on software. Providers sometimes lack the skill set to follow the right practice for prior approval process.
Incorrect Range in CPT Code: Using the right CPT code especially in higher range guarantees payment from the Payer. It is often a challenging situation for inexperienced professionals recruited as in-house staff.