Strategies to maximize the effectiveness of Prior Authorizations

Strategies to maximize the effectiveness of Prior Authorizations

Using automated systems, proactive checks, and expert and dedicated staff are three ways that providers can reduce the bad effects of prior authorizations.

Prior authorization is a strategy that payers use to control cost and ensure that their insured members receive medically necessary care. Advance approval from payers is required to deliver specific services or items for a patient.

Payers use this prior authorizations increasingly to lower their costs and deliver quality care to their members. But this process of getting prior approval for services creates extra burden for providers.

Automate Prior Authorization

According to the Council for Affordable Quality Healthcare, Inc. (CAQH) reports Prior authorization automation process is significantly lagging compared to other claims management processes.

Switching to automated prior approval can streamline the process and prevent errors. Fully electronic prior authorizations can also save providers time and money.

Implementing prior authorization solutions now will allow providers to see immediate financial and clinical benefits while the technology continues to evolve and stakeholders adopt national standards.

Proactively check all requirements

Providers agree that prior authorizations can delay patient access to care. They often have to wait until the payer receives and approves requests before starting treatment. Payers can also deny services or medications, forcing providers to spend time and resources submitting additional documentation or an appeal.

Providers cannot control payer decisions on prior authorizations. Approval may delay the treatment. But providers can implement a proactive strategy to avoid delays in care.

Check prior authorization requirements prior to furnishing services or sending prescriptions to a pharmacy, the AMA advises.

Making sure a prior approval is needed and what is needed for payer approval can prevent medical service claim denials and lost payments.

The AMA suggests that providers monitor payer newsletters, bulletins, and websites for prior authorization changes or updates. Providers should also check with payers at the time of ordering through a standard electronic eligibility request via the practice management system or by calling the health plan.

Dedicated Staff to check prior authorizations

You can create master lists of medications and procedures that require prior authorization, broken down by insurer. If possible, have your staff use these lists to program your electronic health record to alert you when you order something that requires prior authorization or you can outsource your prior authorization process to Medisys. We have trained and certified staff.

Providers should be reviewing requirements regularly, assigning prior authorizations to a staff member, and using technology to prevent major pain points as the industry refines its use of the cost-control strategy.

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