Simplifying Prior Authorization: How to Ensure Timely Medical Approvals

You have analyzed your operations, streamlined your workflow, and trained your staff. However, you are still unable to reconcile the logged services with the reimbursements for your practice.

What is happening? Where are the leaks and losses that you cannot identify?

Have you ever considered the prior authorization process?

It has become a hot topic in the healthcare industry, sparking numerous debates about its inefficiencies and drawbacks.

The heavily regulated healthcare industry involves numerous policies, and navigating through them can feel like a complex maze. However, it is the responsibility of providers and facilities to ensure that the drawbacks of this process do not become apparent.

Prior Authorization Process in a Gist

Prior authorization is a process that requires obtaining approval from payors for medical procedures, medications, or prescriptions before they can be provided to a patient.

This approval guarantees that the provider will receive reimbursements for the procedures or treatments rendered.

Preauthorization services involve several steps. Initially, healthcare providers verify the patient's eligibility for the service, treatment, procedure, or medication. If authorization is required, providers must submit the patient's detailed information, along with administrative data and evidence of medical necessity.

If the submission meets the requirements of the PA criteria, the plan will approve the request and ensure reimbursements.

If the PA is denied, patients or providers can often appeal the decision by providing additional justification or exploring alternative options. Although the PA process can be time-consuming and frustrating for both providers and patients, it ultimately serves as a safeguard to prevent unnecessary or ineffective treatments, thereby helping to reduce overall healthcare costs.

Prior Authorization (PA) criteria are established based on medical guidelines, cost considerations, utilization data, and other pertinent information.

However, a survey conducted by the American Medical Association suggested that, in most cases, providers claimed that these rules are rarely or never evidence based.

What is the Significance of Prior Authorization?

Some people argue that the PA process was primarily designed to protect the interests of insurers. However, like many aspects of healthcare, preauthorization simultaneously affects payers, providers, and patients.

PA process serves as a barrier to unnecessary healthcare costs. When you submit a PA form to the insurer, the payer evaluates the validity of the procedure and, based on established criteria, either approves or denies the authorization.

This step ensures the mitigation of overutilization of medical services and prevents the unnecessary use of unproven, often expensive treatment methods.

Ensuring medical necessity is crucial because healthcare procedures and treatments require a careful balance between the risks associated with the treatment and the potential harm posed by the condition.

If the treatment administered was more intense than necessary, the patient may face unnecessary risks.

Challenges with the Traditional Prior Authorization Approach

For most providers, prior authorization is an ongoing journey filled with extensive paperwork. This process presents administrative challenges that result in a significant waste of time and resources.

Healthcare providers often dedicate a significant portion of their daily schedules to fulfill prior authorization requirements. This practice consumes considerable staff time that could be more effectively invested in delivering high-quality patient care, ultimately leading to improved health outcomes.

For patients, delays in preauthorization services can create significant barriers to accessing timely care. Often, patients abandon the care process due to the tedious and overwhelming nature of the preauthorization process. Consequently, patient health outcomes may not meet expectations.

Outsourcing: An Old Yet Effective Strategy!

While automating the process for real-time decision-making in patient scheduling appears to be a viable solution, the time, costs, and other resources involved in the process are critical factors in decision-making.

In response to the challenges associated with prior authorization services, outsourcing has emerged as a popular and effective solution.

An outsourced prior authorization company employs a team of dedicated experts who are focused on resolving your prior authorization issues.

Not only do the industry's comprehensive practices excel, but the latest technology is also an area in which they shine.

While delegating a critical task such as prior authorization to a third party may appear risky, these companies actually offer a safe and secure environment by comprehensively understanding and adhering to industry regulations.

Not only do preauthorization services provide assistance, but companies like these often offer additional services such as virtual assistance, medical billing and coding, hospital accounts receivable management, denial management, and comprehensive revenue cycle management services.

Discover how a healthcare revenue cycle management company has excelled in delivering comprehensive prior authorization solutions to its clients, thanks to the expertise and versatility of its professionals.