Prior authorization also known as pre-authorization is a routine billing procedure whereby insurance payers review the medical necessity of a prescribed service, treatment plan or medication. Essentially, this process is put into place to ensure sustainable use of medical and monetary resources. However, even though theoretically the process seems quite easy, ensuring prior authorization success can be quite challenging due to strict payer specific guidelines.
For example, practitioners need to submit proper clinical documentation like imaging reports, justification letters, and clinical notes to prove the necessity of the medical service prescribed. It causes administrative overload for practitioners by adding hefty amounts of paperwork, which can hinder patient care. This is where an expert prior authorization company comes into play. These professional companies have the expertise and knowledge to navigate the complex prior authorization requirements and thus ensure proper revenue cycle management for practitioners.
Basic understanding of insurance prior authorization
As discussed above, prior authorization is a pre-approval process, whereby insurance companies review the medical necessity of a prescribed treatment. There are 3 essential steps involved in prior authorization.
Steps | Explanation |
Initiation | This step is all about submitting approval requests. Firstly, billers must identify if the service in question requires prior authorization. If it is, then billers must submit all medical necessity documents along with the approval form which needs to be filled with accurate patient demographic and medical details. |
Approval | If the request is approved, billers will note the authorization number and the validity period. |
Follow up | If the request gets denied, billers are required to conduct constant follow-ups to identify the reason for such rejection. After that they are needed to make necessary adjustments in the form including fixing any missing documentation to ensure timely appeals. |
Navigating all these steps requires precision and dedication, and this is why hiring expert prior authorization services is necessary for practitioners.
Challenges of prior authorization process
Despite its intent, ensuring prior authorization success can be quite challenging. One of the most significant challenges is the high administrative burden of the prior authorization process. For example, as per industry data physicians spend around 12 to 13 hours per week on prior authorization work and manage around 39 to 43 requests weekly. This is not only due to the manual workflow of such approvals but also the fact that almost all medical procedures require such preapproval by payers. For example, around 99% of Medicare Advantage (MA) plans require prior authorization. This causes immense pressure for practitioners as unable to get timely approvals to lead to delayed patient care.
Additionally, submitting accurate medical documentation is another significant challenge. For example, if there are any gaps in documenting a patient’s clinical information, then it will lead to discrepancies in proving medical necessity. This will lead to rejections straightaway. Furthermore, wrong patient data can also lead to delays and rejections of such requests. This is because without correct information, payers will be unable to review the medical needs.
Lastly inconsistency in payer specific rules can also add to the administrative burden for practitioners. For example, the Wasteful and Inappropriate Service Reduction (WISeR) Model initiated by Medicare has recently mandated the use of AI driven technologies to review prior request claims in 6 states for specific high-risk services. This means practitioners will have no place of errors while submitting such requests as they will be reviewed under higher scrutiny by technological models.
This is why partnering with a professional prior authorization company having in-depth understanding of the prior authorization process is a must.
Best practices for streamlining prior authorization
Some commonly applied proactive strategies to ensure prior authorization success include:
- Synchronizing the prior authorization process with electronic health records to reduce chances of manual errors by ensuring automated data entry.
- Conducting internal audits to flag repetitive errors and find strategic solutions to mitigate the same.
- Hiring an external prior authorization company and leveraging their in-depth knowledge on the same.
- Establishing effective communication among billing staff and practitioners to reduce chances of documentation gap.
Amidst all these hiring, a prior authorization company can be most beneficial as it ensures effective delegation of such complex billing processes to external teams. This allows practitioners to shift their focus primarily on patient care.
Ensure prior authorization success with the right outsourced partner
When it comes to hiring expert help, there is no better solution than outsourcing. This is not only because these professionals are experts in navigating strict prior authorization guidelines, but they are also most cost-effective. To begin, prior authorization partners charge as low as $7/hour for their services and even offer a free account manager. This makes them better prior authorization partners rather than an internal team by eliminating the need for in-house staff management. Secondly, the prior authorization partners SunKnowledge is known to ensure 100% same day approval request submission as well as approval within 1.5-2X faster approval rate. This indicates their in-depth understanding and expertise regarding prior authorization processes.
Apart from this, these companies have experience with prior authorization specific platforms like the CoverMyMeds. This further establishes their deep understanding of payer specific guidelines. Finally, these companies are adept at not only prior authorization, but they offer comprehensive revenue cycle management solutions. For example, companies like SunKnowledge submit 70-75 clean claims per day, and even manage 80-100 denial management per day. This is an added bonus for healthcare providers.
If you are also struggling with ensuring prior authorization success in your healthcare practice, then consider outsourcing an expert prior authorization company.
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