Prior Authorization Services, The Guide to Successful Revenue Cycle Management

Prior Authorization

Taking the viewer through the various nooks and corners of the principal revenue cycle management phenomenon called the prior authorization services. Looking at the history and the present developments in the world of prior authorization as offered by the different practice offices across the industry.    

What is prior authorization?

Prior Authorization services refer to checking the insurance provision for the claim components of the medical provider s designed by the RCM practitioner. This is the initial and the most important step in the whole process of Revenue Cycle Management. The lesser time taken to confirm the insurance provision of the various parts of the claim as filed by the practice management, the better are the chances of its recovery on time. Hence behind every successful RCM there is a comprehensive prior authorization process which makes it's fruitful. Thus, as the name suggests it is a pre-confirmation concept of insurance recovery.       

The reason for its existence

The primary reason behind professional prior authorization services is the work accumulation burden due to mishandling of the prior auth protocol by the non-experienced clerks at the physician’s office. Prior Authorization service being a necessity, not all of those who need the business of the same are academically equipped to handle the same. Often, work at the provider’s end would get stalled due to lack of experience and awareness of the associated legalities in it. Hence for the sake of quicker work movement, saving obstacles in doctor’s duties and healthy flow of income prior auth existed as an academic course and professional career.

The process

A typical workflow chart of the prior authorization services at nay pre-auth office is as follows

 Authorization Initiation

It ideally means calling up the insurance company to know the protocol of filing the request, the documentation requirements, turnaround time.

Submitting the request by collecting the form, filing it up, furnishing the required documents.

Keeping a track of the receipt via fax or email       

Authorization follow up
 

Calling up and coordinating with the insurance company to know the actual status of the request thus filed along with furnishing the additional paper requirements    

Authorization acknowledgement

Uploading the final information about the approval or the denial of the request in the provider’s system along with the service information like the start and the end dates of the account bucket etc.   
 

The pros and cons

Prior Authorization Services has many advantages and disadvantages. Some of the major advantages are time management, medical morals, the betterment of patient, provider and payer relationship etc. With the help of prior authorization expensive medical treatment not required by the patient is checked from being prescribed, wastage of time in form of repeated recycling of the RCM process is avoided by prescribing medicines and treatment exclusively provided for in the payer contract. Due to improved income and clarity of services the patient, provider and payer nexus is largely affected in a positive way. However, due to strict prior authorization certain essential medication take a longer time to get approved which is a major fall out of the practice being protested against.    

 
The challenges

The various problems and the solutions to prior authorization services are as follows

Problems

  • Missing information
  • Key-in errors
  • Increased denial rate
  • Increased turnaround time
  • Excess time taken due to limited stuff
  • Secondary verification not carried out
  • Constant follow up required for meeting documentation requirements   
  • Additional clerical work in form of printing, faxing and mailing
  • Delayed filing leading to denials
  • No information about actual status
  • Delayed correction and re-submission
  • Unapplied balance
  • Accumulation of backlog
  • Manual posting
  •  Non-posting of denials

Solutions

  • Transaction audit

  • Employment of limited staff

  • Completion of secondary verification

  • Rigorous audit

  • Proper tracking mechanism

  • EDI based submission

  • Defining KPI for rejection management and assigning roles

  • Review of patient payments

  • Denial posting and review

  • Proper documentation

  • Regular analysis, follow up and review

  • Exception reports  

Trivia

Prior Authorization Services are a must for all physicians’ practice. It is mandatory hence for all doctors to know the rules and regulations of PA while prescribing treatments to patients.

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