WHAT IS PRIOR AUTHORIZATION IN MEDICAL BILLING?
In today’s complex healthcare environment, certain medications and procedures require additional steps before approval, such as pre-authorization. But what is pre-authorization? And why do some medical procedures and drugs require it? This article will demystify prior Authorization and its importance in the health sector.
WHAT IS PRIOR AUTHORIZATION?
Prior Authorization is an “approval from a health plan that may be required before you get a service or fill a prescription for the service or prescription to be covered by your plan.”
Insurance companies use prior Authorization (precertification, prior approval, predetermination, etc.) to determine if a service or product is covered and whether it will be paid partially or fully. Usually obtained before specific procedures or medications are given to patients, prior Authorization can also cause a delay in the care otherwise required. To cover the cost of services delivered, providers must obtain pre-approvals from insurers for which their clients have subscribed.
MEDICINES AND MEDICAL THERAPIES THAT REQUIRE PRIOR AUTHORIZATION
A medical expert must obtain Authorization before a patient receives specific medical treatments. However, medical practitioners don’t need prior authorizations for emergency services as it may hinder timely treatment.
This includes medications that have a high potential for misuse or abuse.
- Cosmetic Drugs
- High-Risk Medications
- Diagnostic Imaging
- Home Health Care Services
- Rehabilitation
- Non-urgent surgeries
- Medical Supplies
IMPORTANCE OF PRIOR AUTHORIZATION IN MEDICAL BILLING
Insurers require pre-authorization for specific procedures and medications for several vital reasons. First, this process helps to reduce the cost of care while ensuring that patients receive only those interventions that provide value and are medically necessary. Additionally, when health plans pre-authorize specific medications and procedures, their members are likelier to opt for less expensive alternatives. Providers can also avoid paying for duplicate services when two or more two specialists advise similar laboratory tests or diagnostics.
IMPROVING YOUR PRIOR AUTHORIZATION PROCESS
DOCUMENTATION
Accurate and error-free documentation is critical to streamline prior Authorization, medical billing and coding. A complete request with proper documentation is recommended. However, if you have incomplete or poor documentation for initial approval, your PA will be declined.
AUTOMATING THE PRIOR AUTHORIZATION PROCESS
The initial step of getting prior Authorization has been described as time-consuming, taking several days or weeks to get approval. There is a need to address this issue, and in this respect, providers should aim to automate prior Authorization. If authorizations are required, they are done electronically between the payer and provider for faster approvals. If a robust platform is adopted for automated prior authorizations in healthcare, the acquisition of pharmacies, payers, and manufacturers will all contribute to quicker turnaround times as the process will be less paper-orientated.
REDUCING SERVICES THAT REQUIRE PRIOR AUTHORIZATION
One way to expedite your prior authorization process is to reduce the required services. To improve your PA process’ turnaround time, ensure you and your staff check prior authorization requirements before providing any service or sending prescriptions to a pharmacy.
CREATING A LIST
Making an all-inclusive list of medical procedures and medications requiring pre-approval is one proven way to streamline the pre-authorization process. This can be achieved by referring to the PA guidelines of your biggest payers or consulting electronic health records to identify drug tiers requiring prior Authorization.
LEAVING IT TO PROFESSIONALS
The most excellent and fastest means of streamlining your prior Authorization is to leave it to the experienced hands of professionals. This aids in quickening the processes relating to your prior authorizations, leaving you with enough free time to concentrate on offering quality care, which you are good at.
CONCLUSION
Prior Authorization is an essential part of the medical billing process that directly or indirectly affects the provision of care to patients and organizational workflow. The burden may be increased, but the reason behind it and the ability to automate make the ordeal worth it. While prioritizing correct documentation and using accurate tools, healthcare providers can perform prior Authorization to allow patients to undergo treatment at the right time. For those who want to make their prior authorization responsibilities lighter, working with professionals can provide a sense of ease and enable providers to focus on caring for their patients efficiently.
