The Burden of Prior Authorizations: How to Alleviate Stress in Your Practice

Most insurance companies have different rules, making it tough for you to handle prior authorizations. On top of that, payers often add new services to their prior authorization list each year. By using specialized prior authorization services, you can lower your stress, and save a lot of time and resources.

The truth is that managing ***prior authorization services*** is not an easy job to handle for your amateur in-house administrative staff members as the recent AMA survey also highlighted some key challenges coming with managing PA in healthcare domain.

Challenges of prior authorization highlighted by AMA survey:

Insurers use prior authorization (PA) to decide if the services your patient needs are medically necessary before they can receive them. However, a 2022 AMA survey revealed that many physicians believe these authorization protocols lead to waste and unnecessary harm to patients. Did you know that 88% of surveyed physicians reported that managing prior authorizations is a high or extremely high burden? To cope with this workload, 35% of them have assigned staff members to focus solely on prior authorization tasks. More than 80% of physicians reported that PA caused delays in getting patients the care they need, which negatively affected their clinical outcomes and even led some patients to abandon treatment.

However, the good news is that you can still streamline the perfect pre-authorization solutions by implementing some excellent strategies mentioned below.

Know about the strategies that a perfect pre-authorization company always follows-

1)Clearly understand pre-authorization coverage and policies set by each insurance company:

Each insurance company has its own prior authorization form that you need to fill out when prescribing a specialty medication or treatment that isn’t covered under their plan. You might have to deal with many different forms, each with its own length and complexity. Take your time to understand and complete these forms carefully to avoid issues.

2) Ensure error-free coding:

Make sure you report the right diagnosis codes to show the medical necessity of the procedure and explain to the payer why the service is needed. This information also helps during reimbursement negotiations. You should also report the correct CPT codes for all possible treatment options. For example, if an orthopedist is treating shoulder pain and is deciding between viscosupplementation or corticosteroid injections, make sure to submit the CPT codes for both options. This way, you’ll ensure payment regardless of which treatment is used.

3) Submission of accurate documentation:

Always remember the fact that incorrect or inadequate information is one of the key reasons behind delayed prior authorization process. You can avoid such a situation by conducting eligibility and benefits check and figuring out whether prior auth is required during patient scheduling or not. You’ll need details like the patient’s insurance ID or SS number, name, date of birth, procedure type, facility tax ID or NPI, and the ordering doctor’s tax ID or NPI. Even small mistakes like wrong numbers or incomplete addresses can lead to denials and more work for your team. Using professional insurance verification services can help you create a reliable verification process for all patients.

4) Know the payer’s criteria to justify the medical necessity:

Payers will only reimburse services that meet their specific criteria for medical necessity. It’s important for you to understand each payer’s definition of medical necessity. For example, Medicare Advantage Contractors use specific guidelines to decide if a service or item is medically necessary:

It must be safe and effective for your patients

The service, procedure or drug must not be the experimental one

It is only perfect for receiving prior authorization approval when provided according to accepted medical standards, in the right setting, by qualified staff, and meets the patient’s medical needs.

When submitting a preauth request, include not just the diagnosis and procedure but also details on how severe the diagnosis is, the risks of not doing the procedure, and any previous treatments or tests. Make sure you close any gaps that could cause extra reviews, denials, or overpayment requests.

Prove if the patient is the perfect candidate for the specific procedure: If a patient needs surgery, the surgeon or referring doctor can write to the insurance company to explain why the procedure is necessary. They can also use evidence-based research to back up their case.

Check insurance companies’ websites regularly: You can stay up to date with insurer policies by checking their website or calling them directly. This information is also in your payer contracts. Be sure to inform your patients about any policy details that might affect them so they can discuss it with their insurance carrier and advocate for themselves and you.

Fortunately, you can overcome all the administrative hassles by ***outsourcing prior authorization services*** to an experienced and professional revenue cycle management company. Pre-authorizations experts in a professional RCM company knows exactly how to streamline the best PA and other billing formalities for your practice so that you can enjoy the best revenue outcome while ensuring the perfect patient care.