It’s important to understand the prior authorization issue through the lens of the insurance company and understand the insurance policy administration process flow versus from the point-of-view of a physician’s. Understanding the health insurance prior authorization process can help you improve compliance and increase approvals.
Insurance companies require a prior authorization prior to the prescription being filled, procedure or service to verify that it’s a medically necessity. If the service is done prior to the insurance plan approving, patients and physicians could be responsible for the full cost, with the insurer paying nothing.
This blog will review the benefits of automating workflow, and how you can improve your overall workflow by automating your prior authorization process. Imagine the efficiencies that could be achieved if your workflow of manual prior authorizations could be controlled, streamlined and automated.
What is the difference between a Referral and Authorization in healthcare?
Health insurance companies differentiate between authorizations and referrals. Some things require authorization numbers while others only require a referral. Authorizations are subject to a member’s benefits, eligibility, and enrollment status. An authorization for services does not apply if benefit limits have been reached. Examples of items that might need authorization numbers include:
- Inpatient services
- Speech therapy
- Home services
- Out of network providers and facilities
- Genetic testing
Referral is the process of sending a patient to another practitioner for consultation or for a service that the referring physician believes is necessary but is qualified to provide. It is the patient’s responsibility to provide a referral to the physician who is treating the patient. If the patient does not provide a referral, then any outstanding balances not paid by the insurance plan may be charged directly to the patient. These differ by payor, but some examples of things that only require a referral can include:
- Office visits for local network participating providers
- Ambulatory procedures are local network participating facilities
- Outpatient hospital procedures at local network participating facilities
- Mammography, sleep studies, outpatient diagnostic imaging
The only way to know if an individual patient’s insurance company requires authorization numbers versus a referral is through a prior authorization system. Detailed information reduces delays in approvals and therefore, delays in the delivery of care.
Centers for Medicare & Medicaid Services VS Commercial Payors
Commercial payors have different prior authorization requirements than Medicare, Medicaid, or Dual Medicare-Medicaid plans. Each plan has specific exclusions that should be flagged by the prior authorization system. Without a cornerstone of detailed information, providers and staff can be initiating patient care without any indication of whether or not it will receive payor approval. That puts the practice and the patient in a financially tenuous situation.
For example, commercial payors may require prior authorization for the following services, while Medicaid may not, depending upon the state:
- Mental health services
- Hip, knee, shoulder arthroscopy
- Genetic, molecular testing
- Medications for cosmetic reasons
Reducing the Burden of Prior Authorization through Automation
It is literally and logistically impossible for any practice to manually review the prior authorization and notification lists of every payor. Given the number of patients on an average physician panel, the frequent changes that insurance companies can make to coverage stipulations, and the wide number of insurance plans and programs that patients may have, the sheer numbers of variables is daunting.
New drugs may also be added to a payor’s prior authorization list as they hit the market, which could be every month. Given the rate at which new drugs are approved and released, it is impossible to keep up. An in-house automated prior authorization system is the best insurance (no pun intended) that a provider can deliver the best drug therapy to his or her patients.
The only way to survive onerous prior authorization burdens is to optimize accuracy and maximize revenue through electronic, automated prior authorizations. Best practices in prior authorization are built on software that delivers the following benefits:
- Timely prior authorizations conducted at the time of patient scheduling
- Accurate prior authorization details obtained for accurate claim submissions
- Automated prior authorization tasks, reducing physician admin time
- Cloud-based tools that provide real-time data to make good decisions about patient payment and scheduling
When you automate your prior authorizations, you’re able to optimize the amount of information you have and maximize its timeliness; the results are more accurate claims and fewer denials, which equates to more revenue for your practice.
Specific Forms for Successful Prior Authorizations
Half the battle for successful prior authorization is using the right form. These requirements can change on a dime, with both commercial payors and CMS. For example, commercial supplemental insurance may or may not accept CMS forms for reimbursement. Knowing this specific detail through automated prior authorization alerts is essential to avoiding unnecessary denials.
Prior authorization is like the shifting sands, and are not likely to go away soon. The only way to control the dynamic environment is with a comprehensive, detailed knowledge of changes in payor requirements. When an in-house system automatically keeps you on top of changes in documentation and forms, you can comply since the information can be passed electronically from the provider to payor. That means your rate of prior authorizations is more successful, which leads to higher revenue and streamlined patient care.