Know How to Overcome the Challenges of Prior Authorization Solution

You know how insurance companies all have their own rules? It makes handling prior authorizations a real headache! And every year, they add even more services to the list that need approval. But when you use specialized pre authorization services, things get a lot easier—you save time, lower your stress, and keep your resources focused on what really matters.

The truth is, handling prior authorizations isn’t easy for your regular in-house team. They’re not experts at it, and even a recent AMA survey points out big challenges in managing PA in healthcare. It’s a tough job, and your team could really use some extra help!

Hurdles of prior authorization services revealed by AMA:

Did you know insurers use prior authorization solutions (PA) to decide if your patient’s care is “necessary” before they can actually get it? But here’s the problem—a 2022 AMA survey found that most doctors think these rules just create waste and can even hurt patients. Can you believe that 88% of doctors say handling PAs is a huge burden? To keep up, 35% of them have had to put staff members on PA work full-time! And it’s not just extra work—over 80% of doctors say PAs delay care, mess up patient outcomes, and sometimes even make patients give up on treatment altogether.

Fortunately, you still can streamline the perfect prior authorization solutions by implementing the strategies mentioned below-

Strategies to streamline a robust prior authorization service:

Comprehend all the pre-auth policies set by insurance companies: You know, every insurance company has its own special prior authorization form that you have to fill out when you’re prescribing a treatment or medication they don’t usually cover. You might get tons of different forms, and each one can be tricky or super long. So, take your time, go through them carefully, and fill them out right to avoid any issues later!

Ensure zero-mistake in your coding process: You need to make sure you report the right diagnosis codes so the payer understands why the procedure is needed. This shows it’s medically necessary and helps when you’re discussing payment. And don’t forget to report the correct CPT codes for all the possible treatments! Like, if an orthopedist is treating shoulder pain and might use either viscosupplementation or a corticosteroid injection, make sure you’ve submitted the CPT codes for both. That way, you’ll get paid no matter which treatment is chosen.

Make your documentation process perfect: You should know that wrong or missing info is a big reason why prior authorizations get delayed. You can avoid this by checking eligibility and benefits ahead of time and finding out if prior authorization is needed when you’re scheduling the patient. You’ll need info like the patient’s insurance ID or SSN, name, birth date, procedure type, facility tax ID or NPI, and the ordering doctor’s tax ID or NPI. Even tiny mistakes, like wrong numbers or incomplete addresses, can lead to denials and make more work for your team. Using professional insurance verification services can help you set up a strong verification process for all your patients.

Justify the medical necessity strongly: Payers will only pay you for services that fit their rules for what’s “medically necessary.” So, you need to know what each payer considers “necessary.” For example, Medicare Advantage Contractors have their own guidelines to decide if something is really needed for a patient. Below are the criteria that you should always consider:

• Make sure the recommended course of treatment is safe and effective for your patients
• You must not prescribe drugs that are experimental
• You’ll only get prior authorization approval if the service follows accepted medical standards, is done in the right setting, by qualified staff, and truly meets the patient’s medical needs.

When you send in a preauth request, don’t just add the diagnosis and procedure. You should also include how serious the diagnosis is, what could happen if the procedure isn’t done, and any other treatments or tests that were already tried. Make sure you cover everything so there aren’t any gaps that could lead to extra reviews, denials, or even requests to pay money back later.

Make sure your patient is the perfect candidate for the treatment prescribed by you: If a patient needs surgery, the surgeon or doctor who referred them can write to the insurance company to explain why the surgery is needed. They can also use research and facts to help prove their point.

Regular check the website of the insurance company: You can keep up with insurance rules by checking their website or calling them directly. You’ll also find this info in your payer contracts. Make sure to tell your patients about any policy details that could affect them, so they can talk to their insurance company and speak up for themselves—and for you!

Luckily, you can get rid of all the paperwork and stress by using a prior authorization company to prior authorization outsource the job. The experts in a professional RCM company know exactly how to handle all the prior authorizations and billing steps for you. They make sure everything runs smoothly, so you can focus on giving your patients the best care and still get the best results for your practice’s revenue.