How to Establish Effective Prior Authorization Process Flows at Your Practice or Facility

News outlets often alarm viewers with stories of insurance companies that refuse to pay due to disputes with the doctor’s specific treatment plan.

Far more often, however, it’s the doctor’s failure to secure prior authorization before providing services that lead to the denial of a claim.

Payors deny just one percent of medical claims based on medical necessity, but failure to secure prior authorization lies behind nine percent of all claims denials.

Don’t let this happen at your facility.

Maximize your paid claims when you put an effective prior authorization process in place that all staff members follow every time.

Step 1: Establish and document all players and systems in the prior authorization flow

Providers, facilities, and staff looking to create an ironclad prior authorization process should start by documenting all entities involved in providing the service. Providers may be standalone with privileges at a facility or employed by a facility. Facilities and providers may have referral relationships with each other as well. All staff should be aware of these relationships.

For instance, a standalone provider practice typically has privileges at hospitals. Practice staff should know upfront which ADT system each hospital has. If a system differs from the practice’s EHR or practice management system, staff should establish how to get the two systems to share information. Also, staff should create a form the patient can take to the hospital or fellow provider that stipulates the service to be received, the timeline, and whether prior authorization has already taken place. All entities involved in the patient’s care should have documented processes for communicating with each other.

When creating a prior authorization process that moves a patient smoothly through the system:

  1. Determine whether you share the same ADT system with the other provider or facility.
  2. Document which departments and personnel you will be working with.
  3. Establish how you will communicate that prior authorization has been initiated and obtained or not.
  4. Coordinate with the other entity about how patient care will move from one healthcare provider or facility to another.
  5. Create a clear form for the patient to take from one provider or facility to another.This form should include:
    • Accurate demographics and insurance information from the patient
    • Insurance verification
    • Procedure and diagnosis codes and in narrative format
    • Physician’s order, if necessary
    • Prior authorization, including process and staff member who completed it
    • Authorization outcome including, number, date or timeframe to complete service

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Step 2: Determine process flows in cases of prior authorizations that weren’t approved

Use the following guidelines to shape your process. With most elements in place, consult with your legal team to finalize. You will need:

  1. A checklist of all options to ensure all solutions have been attempted. Instruct staff to follow this checklist for every case. Often, the provider will contact the patient’s insurance company and maybe provide the insurance company with additional medical records to plead their case. Providers can also explore whether any other insurance option is available. Infinx’s Eligibility+ runs a patient’s information through the system to discover insurance coverage that wasn’t identified during registration. Research shows 5-10% of self-pay accounts that are written off as bad debt actually have billable insurance coverage, and 67% of those denials are recoverable.
  2. Protocol for informing patients. Will you provide the patient with a formal consent form that they have to sign where they acknowledge that authorization was denied?
  3. List next steps for patients including alternative treatments you could provide or contact information of other providers. Providers can also give patients a self-pay estimate to have the procedure performed and make payment arrangements with the provider.
  4. Inform the patient that they can reach out to the insurance company to advocate on their own behalf.

Step 3: Let technology shoulder half of the prior authorization burden

Due to the staff time and effort required in securing prior authorizations, providers and healthcare facilities have turned to AI- and machine learning-powered prior authorization software. Informed by experts with extensive domain experience, this technology uses robotic process automation to deliver real-time status notifications and check requests for status change updates. Providers and facilities can either tie system automation into the current ADT and EMR systems or bring it in as a system plugin.

This software helps healthcare providers:

  • Avoid spending money on new staff hire
  • Relieve staff of excessive prior authorization burdens
  • Prevent prior authorization returns due to insufficient information
  • Determines whether prior authorization is required or not in seconds
  • Provides real-time status updates so you can schedule procedures on time
  • Automated follow-up with payers and real-time status updates provided by our RPA bots to help your staff schedule procedures on time

Prior authorizations will continue to be a pain in 2022

Legislation favoring insurance companies, healthcare staffing shortages, and cuts to Medicare and Medicare Advantage plans all threaten provider and hospital revenues going into 2022. Hospitals and providers must establish ironclad prior authorization processes to protect their bottom lines. Establishing, documenting, and sharing process flows helps ensure more prior authorizations go through upon the first submission.

Automated prior authorization technology not only streamlines patient care, but it also provides impressive business support to referring providers. Typically, once staff recognizes the timely care initiation and streamlined reimbursement that automation enables, they become enthusiasts.

Contact us today to schedule a demo and learn more about the automated prior authorization efficiencies for your hospital or practice.

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