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 it’s 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 patient’s 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.
Tips for Improving Prior Authorization Process
- Document all treatment decisions and back them up with evidence-based practices. Payer’s 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 can’t 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.
- 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 email@example.com/ 302-261-9187