Outsourcing Prior Authorization: When is the Right Time?

2019-05-09T14:34:56+00:00May 9th, 2019|

Why you should consider outsourcing your Prior Authorizations.

Obtaining prior service authorizations can place a significant burden on your staff, but if missed, this critical step in the reimbursement process will cause significant challenges.

If prior authorization is not accurately obtained, or obtained at all, your staff may find that they have allowed you to perform services in vain. That means no payment for the surgery you’ve just done.

There are days when obtaining an authorization is easy peasy, lemon….. And then there’s every day, where just trying to request an authorization has taken more than half of your day.

Mix in trying to get an approval, with appealing a PA denial, and your week has gone by full of stress and time wasted.

Let’s take a further look at this process and see if maybe letting us help you is just what you need!

What are the greatest consequences of inadequate PAs?

From the looks of it, Prior Authorizations are not going anywhere. PAs will remain in demand, driven primarily by health plans ‘ desire to control the rising costs of health care. Below are some examples of what you will deal with in your practice if your PA process is inadequate.

Uncompensated work for medical and administrative staff, leading to increased overhead cost for practices that may already be financially stressed.

Mishaps in practice workflow, leading to inefficiencies in patient care and loss of revenue.

Non-Payment for services rendered because PA requirements were not met or prerequisites were met after completion of medical treatment.

The True Cost of Prior Authorizations

The consumption of physician’s time. Many of our clients had expressed their dissatisfaction with the time it took them and their staff to communicate directly with health plans.

When a procedure requires authorization it takes a lot of administrative time.

When a medically necessary prior authorization gets denied, this takes a lot of the doctor’s time. Peer to Peer sound familiar?

Administratively, there are multiple pre-steps and steps that need to be followed.

This may include obtaining the correct form, completing it with the information required, submitting the form to the plan, etc.

Holding times are particularly long when trying to reach an insurance company’s customer service rep, with hold times of at least 25 minutes or more.

On our recent client survey, results showed that practices spent an overall of 35-65 minutes on each Prior Authorization submission. I am pretty sure we all agree that the time spent on the phone could be put to better use in the office.

Money. So now you’ve spent the time, battled through the burden and frustration and obtained an authorization only to find out that it did not meet criteria and now your surgery has been denied.

Failure to obtain proper PAs can have a powerful impact on your practice’s income. Improper auths + denials = no payment. If the correct prior authorization is not provided, insurance companies will not pay for procedures, and most contracts will not allow you to bill the patient.

Managing the PA process. PA management can sometimes be difficult to control as requirements can vary widely from one insurance company to another, each with their own significant process for submitting a prior authorization requests.

This means that the framework can’t be standardized and must be done manually meaning hours on the phone and/or filling out tedious forms, which can drain time and money.

Steps to help you reduce the Prior Authorization Burden in your practice.

  • Review Insurer’s PA requirements before providing medical services
  • Create a workflow to document information required for PA’s in your clinical documentation.
  • Determine whether or not a predetermination, aka, voluntary preservice review is necessary. This PA method will be needed for procedures that do not require authorization per the member’s plan but can be considered cosmetic.
  • Confirm Receipt and follow up to make sure PA is obtained in a timely manner.
  • If a PA is incorrectly denied, review with the insurance company what the proper appeal steps are. Often times you can overturn the denial with additional medical records. Other times physician involvement will be required via a peer to peer review.

Prior authorization requests are a big source of frustration for medical practices due to treatment delays, manual processes and administrative costs. Many practices currently lack defined roles when dealing with PA, or simply lack time.

Having a dedicated department not only ensures reliability and a stable workflow it also addresses the lack of consistency.

If you would like help in automating your prior authorization process, our prior authorization service can provide the perfect solution. Contact us at 803-807-2844 or email us information@prestigeaccounts.com.

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