Prior Authorization, a Comprehensive Chronicle of The Concept
Prior Authorization is, in a nutshell, an ensuring practice by which a revenue cycle management practice checks the insurability of a particular medical service by getting it certified by the relevant payer company. Here’s summarizing the details of the practice.
What is prior authorization?
In a bid to reduce the cost of treatment and wastage of time, by checking the prescription of unnecessary drugs and therapy by medical practitioners, revenue cycle managers practice prior authorization. Prior authorization or prior auth as it is popularly called is the practice of getting a patient’s recommended medical profile verified with the relevant insurance provider in order to ensure that the treatment prescribed is covered under the particular individual’s insurance policy. There are a number of reasons or contexts against which prior authorization is done. Some such reasons include age, medical demands, need for alternative treatment, genetic requirements like allergies etc.
What is the process of prior authorization?
In the revenue cycle management chain of the patient, provider, and payer, the practice personnel plays the role of efficient mediators. They perform the protocols of verification and recovery by following the established course of action of medical billing of which prior authorization is a part. After a request comes from a medical service provider, the practice manager fills up a prior auth form, furnishing the details of the patient, policy and the treatment prescribed. The process of completion of pre-auth is different for different insurance companies. Ideally, the plea is either accepted, rejected or asked for revision and refurbishing of additional information. In many cases, an alternative practice is adopted called the ‘fail first’ or step therapy. Under that, an alternative treatment is recommended by the insurance company for being less costly or more medically safe. If that treatment fails to have the needed effect on the patient, the payer contemplates an alternate coverage.
What is the purpose and expenses associated with prior authorization?
The main purpose of prior authorization is to control indiscriminate medical prescriptions. In other words, the practice of recommending redundant treatment and expensive medicines, when economical alternatives are available, is countered by prior authorization, by checking the extent of insurance coverage of the patient. It is also useful in avoiding medications that are not safe to use for all and sundry. Apart from saving the cost and danger of unknown and ill-fated drugs, prior auth also goes a long way in saving the time of revenue recovery by filing and furnishing only those medical prescriptions which are allowed and covered under the insurance plan. However, if pre-auth is attempted by non-professionals like doctors and their staff, it can be a huge time and cost consuming affair. Hence the role of efficient medical billing practices who can afford the same at minimum cost and time.
Important facts about prior auth
In order to do away with the shortcomings of the process and make it more effective and objective based, there have been many efforts recently. Recommendations have been for electronic pre-auth process instead of the manual one, along with instant insurance feedback and back appeal facilities. Digitalization of the process would be the mean reduction of considerable cost and time for the practice, a system that has been increasingly adopted by premier revenue management companies.
Denial management is an important part of revenue recovery and works in tandem with pre-auth services. Rejection or refusal for insurance acknowledgment often leads to repeated appeals which complicate the process. In order to avoid repetitions, the following guidelines are followed by any reputed medical billing company.
- Being abreast of the services provided, the patient and the provider
- Being in touch with the payer to certify the pre-auth request
- Being abreast of the patient’s eligibility
- Being abreast of the insurance rules before taking on pre-auth requests
- Being updated on the auth status
- Following up with the treatment details
- Updating additional information if required
- Updating the internal system with pre-auth information
Prior Authorization goes a long way in smoothening the revenue cycle management process. It is one of the most important aspects of the revenue generation process, which when entrusted to a reliable practice, can work wonders in making medicine easy for all.
Similar Articles
Chronic pain is a medical problem that affects many people around the world. Unlike acute pain, which is a short-term response of the body to tissue damage, chronic pain lasts longer, often without obvious physical damage. It can last from several months to several years, and its consequences can affect all aspects of a person's life
When was the last time you gave your veins some love? These hardworking highways of blood don’t ask for much—just a little support and, occasionally, professional attention when they’re not performing at their peak.
These small plastic containers are a household staple, but disposing of them incorrectly only adds to the growing waste issue. Learning to eco-dispose pill bottles reduces your footprint and shows love and respect to the planet and future generations.
We often experience small discomforts or symptoms that seem insignificant, like headaches, fatigue, or brittle nails. Many times, we brush them off, thinking they’ll go away on their own. However, these minor issues might be your body’s way of telling you that something more serious is going on.
According to the World Health Organization (WHO), half to three-quarters of adult persons globally experienced a headache in the past year. Unfortunately, tension headaches are one of the most prevalent symptoms you can have. Furthermore, some tension headaches resemble migraine headaches, making matters worse.
The review of Yakrit Plihantak Churna is going to be amazing. You will know the facts, does it works along its benefits. The liver is the main engine of the body. It is the second largest gland in the body.
A podiatrist is a doctor who focuses on treating foot and ankle ailments. If you have specific medical issues, you may need to see a podiatrist for therapy that your primary doctor cannot offer. Don't overlook pain in your lower leg, foot, ankle, or toes.
A podiatrist is a medical expert who focuses on foot and ankle care. There are various reasons you may need to see one.
Swelling is a common issue that can strike anyone. Occasional leg swelling may occur after a long day on your feet or from sitting too long. However, if your legs are regularly swollen, it could indicate a serious underlying condition. Swelling can cause leg pain, loss of sensation, redness, and itching. If left unmanaged, it can lead to stiffness and difficulty walking.