Prior authorization for medication recording is still one of the most difficult tasks to manage in the entire medical billing cycle, despite the ongoing discussion over whether it is necessary and whether it unintentionally interferes with patient care. Prior authorization is essentially a preventive and corrective technique used by insurance companies to reduce needless healthcare overspending, but it can easily consume back office resources and reduce overall productivity.
This is mostly because obtaining prior authorization for a specified treatment, supply, or medication is not an easy process and cannot be finished quickly.
It involves submitting numerous faxes and phone calls, gathering copious supporting evidence for each such request, and waiting for a long time before the insurance provider makes a decision. And when you have a lot of prior auth requests to finish in a day, your billing staff can go crazy.
Issues With Pre-Authorization
Pre-authorization depends heavily on accurate diagnosis and provision of the appropriate medical billing and coding. The secret to obtaining pre-authorization quickly is accurate coding and documentation of the necessary process before the treatment. This is frequently a difficult task. The function and responsibility of a coder are crucial to this process.
Additionally, on occasion, certain procedures would have been planned, and as a result, prior approval would have been acquired. However, depending on several variables, such as the patient’s health, additional medical treatments can be needed once the patient has had their treatment. Some alternative operations could therefore be carried out without prior authorization. Due to the lack of consent, there is a very high likelihood that the payment will be rejected in these circumstances. Therefore, it is preferable to obtain authorization for treatments that would be necessary for a specific patient rather than having a claim rejected for payment due to a lack of authorization. When a process is allowed but not carried out, there is no punishment.
In an emergency, patient care begins without first receiving pre-authorization. This scenario frequently occurs in cases of illness or accidents that occur on weekends or at night. In such cases, the healthcare professional must get in touch with the insurance payer as soon as possible to request and acquire the necessary authorizations.
How Does the Need for Medical Care Affect Pre-Authorization?
The hospital must decide whether to absorb the expense or charge the patients when health care providers are unable to obtain the required clearances and the payer (insurance company) denies payment. Procedures not covered by the patient’s health plan are explicitly defined and noted during the verification process. When a patient receives services or treatments that their insurance does not cover.
However, when claims are rejected owing to the provider’s failure to obtain authorization, they must bear the expense themselves, which results in a financial loss that affects the entire revenue cycle.
In some circumstances, the patient receives a bill for the unpaid amount, and they are then responsible for paying it. However, doing so would be wrong and would harm the hospital’s standing. Therefore, getting pre-authorization at the appropriate time is crucial to getting paid for the treatments provided.
To guarantee a seamless procedure, some of the best practices for pre-authorization medical billing services are as follows:
- Carrying out an extensive verification process to determine the services covered to acquire pre-authorization
- Keeping accurate records of all pertinent information and thorough documentation
- Upholding cordial connections with insurance companies
- Being aware of the contract conditions and procedures of different insurance providers and following them to prevent delays and denials
- Using standardized templates to prevent documentation and mistakes made by humans
- Providing essential training to staff for all necessary processes.
Typical Practices That Need Preauthorization
Before visiting a specialist, many insurers demand that patients first receive recommendations from their primary care physician. Insurance companies frequently require preauthorization for hospital admissions that don’t go through the emergency room. Additionally, preauthorization or “prenotification,” which is more complicated than a referral but less burdensome than a pre authorization, is frequently needed for imaging examinations including MRIs and CT scans. Providers must include the authorization number they receive as a result of these procedures when submitting claims for payment.
When a patient doesn’t have a referral, preauthorization, or prenotification, different providers have varied policies regarding what they should do. While some healthcare professionals may proceed with a procedure and attempt to gain authorization retroactively, others may postpone treatment until the appropriate authorizations are received.
In search of a solution
It’s understandable why prior authorization is frequently cited as one of the main causes of employee burnout or people voluntarily terminating their employment in the billing & collections department. The issue is that, despite their distaste for it, healthcare providers cannot afford to ignore it.
Getting your prior authorizations organized and finished on time is crucial for your revenue and collections. After all, neither you nor your patients would appreciate the insurance company underpaying them.
Having to deal with all the typical inconveniences of prior authorization leads logically to the need to discover a solution that would simplify life for everyone. The process in this situation should be outsourced to an expert, outside company. Your complete revenue cycle can truly benefit from a trained and capable billing partner who is willing to handle all of your preauthorization obligations.
Such specialized intervention has the potential to improve work-life balance, decrease denials, increase overall collections, and stabilize revenue flow. It can also free up resources for you to work on other crucial projects for your company. Outsourcing with the best healthcare provider solutions like Cyberhelp health solutions can be a fantastic choice. We believe in employee welfare and retaining its workforce for longer.