Written by The fact is that most insurance companies have different policies and regulation for obtaining prior authorization request, making it challenging for you to handle prior authorization for medical services. Furthermore, insurance companies frequently add new services to their list of prior authorization. With the help of a professional prior authorization company, you can reduce your stress and save a considerable amount of time and resources.
Managing prior authorization services is not an easy affair, especially, when your in-house staff members do not have adequate experience in this domain. Recently, an AMA survey shared some critical challenges that administrative staff members often encounter when managing prior authorization solutions.
Critical challenges for prior auth services:
Insurance companies use something called prior authorization (PA) to figure out if you really need a service before you can get it. But guess what? A survey from 2022 found that a lot of doctors think these rules can actually waste time and even hurt patients! Can you believe that 88% of doctors said dealing with prior authorizations is a super big hassle? To make it easier, 35% of them have had to get extra help just to handle all those PA tasks! More than 80% of doctors said that prior authorization makes you wait longer to get the care you need. This can really mess up how well you feel and even make some people decide to stop their treatment. That’s not good at all!
Fortunately, you can still streamline a perfect prior authorization for medical services implementing the tips mention below-
Tips for your prior authorization experts:
1) Have a clear understanding of PA rules:
Each insurance company has its own form you need to fill out when you want to prescribe a special medicine or treatment that isn’t covered by their plan. You might find a lot of different forms, and some can be really long and tricky. Make sure to take your time to read and fill them out carefully so you don’t run into any problems!
2) Practice accurate coding:
Make sure you write down the right diagnosis codes to show why the procedure is really needed. This helps explain to the insurance company why the service is important and can help when you’re talking about getting paid back. You should also include the right CPT codes for all the treatment options. For example, if an orthopedist is helping with shoulder pain and is thinking about using viscosupplementation or corticosteroid injections, be sure to send in the CPT codes for both. This way, you’ll get paid no matter which treatment is used!
3) Ensure an error-free documentation process:
Always remember that giving wrong or not enough info is a big reason why prior authorization takes so long. You can avoid this by checking if the patient needs prior auth when you’re scheduling their appointment. You’ll need details like the patient’s insurance ID, name, date of birth, what kind of procedure they need, and some IDs for the facility and the doctor. Even little mistakes, like wrong numbers or missing addresses, can cause problems and make more work for your team. Using professional insurance verification services can help you make sure everything is checked correctly for all your patients!
4) Know about the criteria set by payers:
Insurance companies will only pay for services that match their rules for what’s necessary. It’s super important for you to know how each insurance company defines medical necessity. For example, Medicare Advantage Contractors have their own guidelines to decide if a service or item is really needed.
The service, procedure, or medicine you use has to be safe and really help your patients. It can’t be something new or experimental. To get prior authorization approved, it has to follow the accepted medical standards, be done in the right place, by qualified people, and meet what the patient really needs!
When you send in a pre-auth request, make sure to include not just the diagnosis and procedure, but also how serious the diagnosis is, the risks of not doing the procedure, and any past treatments or tests. You want to cover everything so there aren’t any gaps that could make them ask for more reviews, deny it, or ask for extra payments!
