Tips For Improving Prior Authorization Process

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Tips For Improving Prior Authorization
Process
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Tips For Improving Prior Authorization Process
As a practice owner, your main focus is always on
patient care. But due to constantly changing
billing guidelines and insurance carrier-specific
policies, you find yourself arguing with someone
from an insurance company about reimbursements.
For example, one day the insulin NovoLog is
covered and then the next day it changes to
Humalog, and now the patient has to switch, and
its very confusing. And if you want to keep them
on the same one, you have to put in the prior
authorization, and the insurance company wants
them to try the other one first. This
back-and-forth costs the practice time and money
and could put the patients health at risk. Even
though there are lots of billing challenges to be
discussed, in this article, we shared a few tips
which will help in improving the prior
authorization process. Basics of Prior
Authorization Prior authorization refers to the
process wherein the payer authorizes to cover the
prescribed services before the services are
rendered. Prior authorization is also called
pre-authorization or pre-approval. As the name
suggests, approval has to be obtained from the
insurance carrier for the proposed treatment or
services. During the insurance eligibility
verification process, we must ensure to verify
what services require prior authorization. The
approval is based on the insurance scheme of the
patient. A pre-authorization number is given by
the insurance provider which has to be quoted in
the final claim form which will be submitted post
the treatment is completed. Pre-authorization in
medical billing helps in the hassle-free claim of
bills. Note that, prior authorization does not
guarantee insurance reimbursement. However, not
having a pre-approval can result in non-payment.
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Tips For Improving Prior Authorization Process

• Tips for Improving Prior Authorization Process
• Document all treatment decisions and back them up
  with evidence-based practices. Payers
  justification for prior authorizations is that
  physicians are not always following the latest
  evidence-based practices, so ensure all treatment
  decisions are based on the latest guidelines. If
  a prescription is not following the formulary,
  make sure all information as to why it is not is
  included in the prior authorization form.
• Create a spreadsheet outlining what treatments
  and medications for frequent diagnoses require
  prior authorization by the payer and what the
  permitted alternatives are. This quick-reference
  guide can save physicians time by directing them
  toward treatments the insurance company will
  accept.
• Maximize the use of technology. 21 percent of
  prior authorizations were submitted
  electronically in 2019. Most payers offer online
  forms for the prior authorization process and
  some EHRs integrate directly with payer
  formularies. The more practice can use these
  online forms, the more quickly authorization can
  be obtained. In many cases, any missing
  information will be flagged before submission.
• Assign a staff member for every payer. This staff
  member can become an expert on the payers for
  which they are responsible, learning their
  specific expectations and what to avoid. A good
  relationship with the payer may help expedite
  claims and appeals. This person should also
  create a basic guidebook for each payer that
  others can follow if needed. Obviously small
  practices cant afford to have payer-wise staff
  members.
• Prepopulate forms for each payer. In some cases,
  you may be able to create a pre-populated form
  that has common information from the practice
  already filled in. This just leaves the specific
  patient information to be added. Although the
  time savings may be small for each form, it can
  add up when multiplied over the course of a year.

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Tips For Improving Prior Authorization Process

• Fight to get rid of the prior authorization
  burden. Most professional medical societies have
  come out against prior authorizations and are
  pushing for legislation to limit their use. Check
  with your organization to find out how you can
  help. Write to your state and federal
  representatives and explain how the process harms
  patient care and raises health care costs.
• Medisys Data Solutions is a leading medical
  billing company providing prior authorization
  services. We conduct eligibility and benefits
  verification for every patient visit and check
  the requirement of prior authorization. Our team
  is well versed with payer-specific and medical
  specialty-specific prior authorization process.
  By submitting a prior authorization request in
  the required format, we take the
  pre-authorization number from the payer and
  mention it in field 23 of CMS-1500. To know more
  about our prior authorization services, contact
  us at info_at_medisysdata.com/ 302-261-9187

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