The criticality and length of prior authorization process makes it one of the most important and complicated areas in medical billing. Furthermore, the set of intricate norms in preauthorization requirements in the healthcare realm not only increases the complexity of the billing process but further delays the overall PA process, reducing patient access to the required care.
Why Pre-authorization is Important?
PA plays a pivotal role in healthcare by ensuring cost-effective and appropriate medical treatments. It acts as a preventive measure against unnecessary procedures, helping to regulate the quality of healthcare.
When the insurers try to determine the criteria for medical necessity, they look for the reliability of the services required. You need to accurately document the required services for a treatment to ensure there is no duplication of the services.
What Happens if You Don’t Obtain Prior Authorization?
In most cases, the payer policies govern who oversees the bills in case of no PA. When as a provider you might be held responsible for paying the bills according to some health plans, others focus on patients.
If you don’t obtain PA for a particular service, you cannot render the same and thus your quality of care will be reduced. Not only that, if you go for surgery without a PA, your claims get denied and you face a decline in revenue.
Each payer has their own set of inclusions and exclusions when it comes to preauthorization. Along with this, the frequent change in their guidelines makes the authorization more complex.
Best Practices in Prior Authorization
Plan for denials: There are plenty of reasons for PA denials. However, you need to focus on comprehensive regulations. Along with that, you must implement a robust plan of action to reduce and overcome the denials.
Double-check codes: During documentation make sure you recheck the codes for the required services to avoid rejection.
Implement technology: More than 80% PAs are obtained manually, by phone or even through fax. This leaves room for errors and increased claim denials. You need to implement advanced technology within the process to reduce human errors. Furthermore, you can consider the implementation of data analytics to gain insights into the reason for PA denials and patterns within the same.
Outsourcing: In today’s healthcare landscape, most of the practices are opting for outsourced partners. An outsourced revenue cycle management company can assist you in obtaining preauthorization more efficiently with their comprehensive knowledge of medical coding and billing. Furthermore, you can have a resourceful team with the security and functionality of the latest technology.
The Bottom Line
The process of getting prior authorization plays a key role in ensuring right patient care and cost control in healthcare. Even though PA might cause treatment delays, you must obtain it for secured care. To provide the best care you must go for authorization. The tedious process of PA seems troublesome when you must carry out clinical responsibilities simultaneously. To maintain the quality of care while ensuring a compact administrative process you can use an outsourced partner as your operational hand. With some effective steps you can eliminate your administrative complexities while providing efficient patient care.
Sunknowledge Services Inc. – an ISO 27001:2022 certified, American-owned & operated company, headquartered in New York City – is a leading global provider of Business and Knowledge Process Outsourcing services in the US healthcare domain.
