Managing Authorization In RCM

Are you facing delays in patient care & inefficient workflows? Prior authorization management is growing heavier day by day due to a huge administrative burden. It has become a cumbersome process filled with manual tasks and roadblocks that dilute the original intent. However, it was created to improve safety, streamline workflows, ensure care standards continuity, and regulate costs. A medical practitioner must understand that it is an important part of healthcare revenue cycle management. Handling it properly is the key to the success of healthcare organizations.

The prior authorization process involves an illustration of a PA form to an insurance firm by a healthcare provider for identifying why a specific medicine or procedure prescribed is essential. In this blog, I will highlight the importance/need of the PA process and ways to manage it effectively.

What Is Prior Authorization?

Healthcare providers need a signoff that will ensure that a specific process is already covered for a patient. Even before the patient qualifies for coverage or insurance agencies agree to pay for medical procedures and medications, etc. This whole process is commonly referred to as precerts and is also known as pre-certification or (PA) prior authorization.

Significance Of PA In RCM

Non-approval after treatment can lead to a huge bill either for a healthcare provider or patients that are the reason PA is crucial in revenue cycle management. Though, it takes a lot of valuable time for medical practitioners whose main goal is to provide quality healthcare services to the patients. So, errors in prior authorization not only affect patient care but also cripples the RCM function.

The Pre-Certification Process

  • Why do you have to wait so long to get the approval for the necessary procedure? After treatment non-approval can cost a huge bill either for a provider or a patient.
  • Healthcare providers have to contact the payers regarding the approval process of necessary procedures when an insurance company doesn’t approve certain medical equipment or treatments.
  • For instance, a cardiologist may prescribe a CT scan to a patient, but it may have already been recommended by a pulmonologist two weeks before for the same patient. The insurance agency will not pass the particular healthcare process unless there is a need for an additional scan and it is clear that the past scan has already been reviewed.
  • In addition to this, it is highly important to ensure that the information supporting the medical necessity claim is accurate and true. Administrative staff will sometimes begin documentation by evaluating PA rules manually for the particular coverage plan linked with the patient because healthcare and clinical billing systems are rarely integrated
  • A provider’s administrative staff may be referencing out-of-date rules as they change frequently. Within a specified payer, it is not uncommon for the rules to even differ from health plan to health plan as they are not standardized.
  • The provider can submit the claim to the insurance payer after confirming that prior authorization is not required. But that does not mean the claim will be approved significantly.
  • Once the payer confirms authorization is needed, it will require to get a number assigned by the insurance carrier that corresponds to the request of the PA. In addition to this, the required CPT codes for the particular procedure are needed to track down and include when the final claim is submitted.
  • Until the resolution of the pre-certification request_ a denial, redirection, or approval, it is the responsibility of healthcare providers to keep a follow-up with the insurance agency. This part of the process can lead to significant wasted effort or time as it is often improvised and restructured.

Topmost Advantages Of Prior Authorization

  • Identify whether the recurrent and ongoing service is worthwhile for the care of patients.
  • Ensure that the drug or service is truly medically necessary that is requested by the physicians.
  • Manage the possibility of overprescribing and help in controlling costs.
  • Make sure services are not duplicated in cases where patients are dealing with multiple specialties.

How Long Does A PA Take To Approve?

Depending on requirements stipulated by the payer, the level of manual work, and the complexity of PA requests, it can take a day to a month to process. The delay can cause problems for both patients and healthcare providers. Moreover, obstacles like postponement decline the patient’s adherence to treatment and medication.

Taking professional support and utilizing advanced lab billing solutions may help to reduce the amount of time a pre-certification takes. So, you would be able to keep a very strict follow-up schedule and know when the first request was sent. This helps you to prevent the dreaded delay that is typically caused by prior authorization.

The Bitter Truth

The inability of advanced tools to reconcile the incomprehensible variables of health plans having pending request PA forms creates significant technology gaps. As the below-mentioned graph depicts

This graph shows past industry-wide adoption rates of the 2017 CAQH index. Though 70% e-prescribing, 87% of physicians with primary care have adopted EHR, 92% of PA is being done manually and 8% utilize digital PA. What we seem to have is a gap on the part of the insurance industry rather than a technology gap. How to bridge the technology gap let’s look at proactive ways to handle PA in the revenue cycle management.

Secret Ways For Managing Prior-Authorization In RCM

Accurate Documentation

Many healthcare professionals do not consider the hectic procedure of prior authorization as they think it a waste of time. However, it only leads to denials when you take shortcuts methods. It’s better to correct it the first time to avoid these issues. Healthcare providers may still find it challenging to take further steps as currently more drugs are getting into the ambit of PA and many new insurance plans are adding up. Many of them have also begun shifting to electronic pre-certification to handle documentation thoroughly and free their precious time.

Secure PA & Patient Health Records

Your priority must be data security and privacy while managing the prior authorization or patient health records on the EHR system. All healthcare entities should avoid disclosure of Patient Health Information (PHI) and must abide by HIPAA. Everything must be maintained securely such as; provide authorization to the system, wireless, password limitations, and access controls.

Approval Makes Documentation Easy

Some insurance agencies in advance may approve particular treatments and prescriptions. This results in efficient RCM when the documentation process may become easy to proceed. Approved pre-authorization may result in irrelevant billing costs both from insurance company ends and the patients. Besides, it is not sure if the insurance agency will cover all costs or not. So, it is recommended to give accurate data during the clinic visit on the fixed amount payable. Patients pay the percentage of health visit costs while the initial amount is paid before the coverage plan pitches in.

Leverage Advanced Technology

Prior Authorization is also getting modified into tech advancements as the US healthcare industry began to embrace a vast technological change. Nowadays, modern lab billing solutions allow you to automate prior authorization and eligibility verification. This superpower has the latest functionalities to decrease the authorization process time, synchronize/access patient medical records, reduce cost burdens, and cut down authorization errors. Furthermore, the electronic PA easily finds a or (HCPCS) Healthcare Common Procedure Coding System code and (CPT) Current Procedural Terminology code.

The electronic authorization sends a final report for prior approval to cover diagnostic procedures, identify the necessity, and collect data from the visit notes by matching these codes with the insurance rules. Hence, utilizing the latest clinical lab billing solutions enable you to stay up-to-date with the tech advancements for better prior authorization.

Role Of Patients In The PA Process

Prior authorization is not only for payers and the healthcare providers but patients also play a crucial role in this procedure. Because they also have to understand the exclusion/inclusion criteria of insurance carriers and need to share information.

Administrative staff must assure that the subsequent patient information is collected correctly before starting the prior certification process. It involves the patient’s previous treatment details, complete-provider notes, comprehensive medical history, symptoms, conditions & diagnosis, etc. Most of the non-emergency and emergency treatments were not qualified or covered by insurance agencies for PA. It is the responsibility of every patient and healthcare provider to double-check the details as each insurance agency has its own laws in granting prior authorization.

In the end, the healthcare industry is full of numerous practical measures to improve prior authorization. Adoption of the latest technological standards for PA and continuous monitoring of treatments, procedures, and medical equipment that require certification will help to optimize prior authorization. At Laboratory Billings, we provide you access to the latest technology to file and document your PA. Our leading lab billing teams will help you to attain your business goals by taking care of your entire pre-certification process efficiently.