Dealing with prior authorizations can be tough since each insurance company has its own rules. Plus, payers often add new services to the prior authorization list every year. By using specialized insurance authorization services, you can simplify the process and get approvals faster.

AMA survey points out some of the critical pitfalls of prior authorization:

Insurers use prior authorization (PA) to check if a service is medically necessary before a patient gets it. But according to a 2022 AMA survey, doctors said these protocols cause unnecessary waste and harm. About 88% of doctors reported that PA is a big burden, with 35% assigning staff just to handle it. Over 80% said PA delays access to care, negatively affecting patient outcomes and even leading some patients to abandon treatment.

Getting preauthorization quickly depends on having the right diagnosis and medical codes for your medical billing practice. Proper coding and documentation before treatment are key, but it can be a tricky process. That's why your coder's role is so important in making it all happen smoothly.

Sometimes, surgeries are planned, and preauthorization is obtained ahead of time. But after treatment, other medical procedures may be needed based on the patient’s condition. If those extra procedures are done without approval, payment might be denied. That’s why it's important to get approval for any necessary treatments upfront to avoid claim rejection. Plus, there’s no penalty if a preauthorized treatment isn’t performed.

In a medical emergency, like a weekend or late-night accident or illness, patient care often starts before preauthorization is obtained. In these cases, your healthcare provider should contact the insurer as soon as possible to request and get the needed approvals.

In your prior authorization services, the medical necessity of the course of treatment that you are going to provide plays one of the most vital roles. Now, it’s time to know the reason behind it.

Why does medical necessity play a major role in your pre authorization service?

If your healthcare provider doesn’t get the right preauthorization and the insurance denies payment, they have to choose whether to cover the cost themselves or charge you. During the verification process, they usually check what your insurance covers. If your insurance won’t cover a service, you will need to pay for it.. But when claims are denied because the provider didn’t get approval, they have to cover the cost themselves, leading to a revenue loss that impacts their entire billing cycle.

In some situations, you need to send the invoices of unpaid amounts to your patients and it becomes their responsibilities to pay the bills. However, such kind of practice would only damage your facility’s reputation and cause patient dissatisfaction. This is exactly obtaining prior authorization approvals at the right time is critical for receiving reimbursements and ensuring zero to minimized out-of-pocket expenses for your patients.

Fortunately, you can ensure the perfect pre authorization solutions by implementing some highly effective mentioned below-

Highly effective practices for obtaining pre authorization:

Navigate each payor’s pre authorization policies clearly:

Each insurance company has its respective prior authorization form for prescribing specialty medication or some specific courses of treatments. You must need to know how to fill up different PA forms and each comes with its own complexities.Take the time to understand and complete these forms correctly.

Ensure error-free coding:

Make sure you report the right diagnosis codes that explain why the procedure is necessary. This information can help during reimbursement negotiations. You also need to include the correct CPT codes for all treatment options being considered. This way, the provider can receive payment, no matter which injection is used.

Submission of accurate information:

One main reason prior authorizations take so long is that incomplete or incorrect information is sent to the health plan. Before scheduling appointment with a patient, you must check their insurance eligibility and benefits carefully. Also, don’t forget to know if the process requires prior authorization. You need to capture critical information like the patient’s ID number from their insurance card or SS number, name, date of birth, procedure type, the tax ID or NPI number of the facility, and the ordering doctor's tax ID or NPI numbe

Know and justify the medical necessity:

Insurance companies will only pay for services that meet their specific criteria for medical necessity. Make sure you understand what each payer defines as medical necessity.

In conclusion, managing prior authorizations can be a complex and time-consuming process, especially with each insurance company having its own rules. However, by prior authorization outsourcing to a specialized prior authorization company like Sunknowledge, you can simplify this process and improve your approval rates. They enable healthcare practices to navigate the intricacies of insurance requirements, ensuring that all necessary information is submitted accurately and on time.