5 mins read
July 23, 2020
In recent times, Prior Authorization (also known as Pre-certification) is one of the trending terms in the healthcare industry. From this article, you will get a clear picture of Prior Authorization, why it is important in RCM, and the most effective tips to handle PA in your practice.
Even before insurance companies agree to pay for medications or medical equipment, healthcare providers require a signoff that a particular treatment will be covered for a patient; this process is known as Prior Authorization (PA).
You may still have some queries like, who uses this PA? For what purpose they are using it? Not the doctors, the health insurance companies make use of this Prior Authorization to verify that a certain treatment or drug is medically necessary before it is prescribed.
Prior authorization is very important in revenue cycle management (RCM) as payers need to confirm whether a particular medication or procedure will be approved. If an insurance company does not approve certain treatments or medical equipment, healthcare providers should wait till they get approval, or else they need to contact the insurance providers regarding the approval process and then perform the necessary steps.
For example, a lung specialist may recommend a chest CT scan for a patient, but the same scan may have already been prescribed by a heart specialist for the same patient before two weeks. The insurer will not approve the medical procedure unless it is clear that the previous scan has already been reviewed and there is a need for an additional scan.
Why do you need to wait till you get approval for your treatments? Because non-approval after treatment will lead to a huge bill cost either for the patient or healthcare provider. So, the omission of the PA process not only disturbs the RCM function but also affects patient care.
Most healthcare providers won’t prefer the lengthy prior authorization process, as it consumes most of their precious time. But taking shortcuts in PA procedures will only lead to denials. To avoid this kind of issue, it better to make it right for the first time.
Nowadays many new insurance plans are coming to play and more drugs getting into the ambit of PA, healthcare providers may still find it challenging to take further steps. So prior authorization has now become a cost-saving approach. Many providers are also started moving to electronic PA to manage documentation better and save time.
Some insurance companies do approve specific prescriptions and treatments in advance. In such cases, the documentation process becomes easier to precede which results in efficient RCM. In the process of approved pre-authorization sometimes gets complaints about the irrelevant billing cost both from the patient end and also from the insurance company. It is not a guarantee and necessary that the insurance company will cover 100 percent of the costs.
That’s why it is recommended to provide the correct information on the fixed amount payable during the doctor visit, the initial amount payable before the insurance plan pitches in, and a percentage of health visit costs payable by the patient.
The PA process is not for the healthcare providers and the payers. The patient also plays an important role in the pre-authorization process. Why because they need to share data and also understand the inclusion and exclusion criteria of the payer.
Before initiating the PA process, healthcare providers should ensure that the following patient data is collected accurately. This includes Patient’s complete medical history, previous treatment details, conditions, symptoms, & diagnosis, detailed provider notes
Some of the emergency and non-emergency treatments won’t be covered by the insurance companies and it will not qualify for PA. As every insurance company has its own rules in granting prior authorization, it’s the responsibility of every healthcare provider and the patient should cross-check with the details well in advance.
As the healthcare industry started attaining a vast technological change, the Prior Authorization is also getting transformed into technological advancements. Today, numerous software applications are developed to perform PA along with access to Electronic Health Records (EHR). This kind of superpower software has the advanced functionalities to access and synchronize patient medical records, cutting down PA errors, and decreasing the authorization process time and cost burdens.
The next big thing to notice is the advanced Electronic Prior Authorization – easily recognize a current procedural terminology (CPT) code or Healthcare Common Procedure Coding System (HCPCS) code.
The electronic PA matches these codes with the insurance rules to identify the necessity, collect data from the visit notes, and send a final report for prior approval to cover diagnostic procedures. So it is recommended to be updated with the technological advancements and adopt the latest solutions for better PA.
Privacy and information security should be your priority when managing the patient health records and Prior Authorization on Electronic Health Record (EHR) platform. Password controls, access authorization to the system, access controls, wireless and physical controls everything should be maintained securely.
There are plenty of effective ways to improve prior authorization in the RCM industry. Regular monitoring of procedures, treatments, and medical equipment that require PA and adoption to the latest technological standards for PA will help to optimize prior authorization.
We at CapMinds have powerful access to the top technological software for creating and documenting your prior authorization. Our well-experienced team will take care of your complete PA process and help you to attain your business goals.