Managing Claims Denied Due Absence Of Prior Authorizations

1
Managing Claims Denied Due Absence Of Prior
Authorizations
2
Managing Claims Denied Due Absence Of Prior
Authorizations
Providers always want to provide the right care
to the patient as quickly as possible, while the
health plans want to ensure treatment choices are
appropriate, legitimate, and cost-conscious. The
definition of appropriate and legitimate
treatment has been updated constantly by
insurance carriers creating a lot of issues for
providers. American Hospital Association (AHA)
recently conducted a survey on how providers are
managing prior authorizations. 940 out of 1,000
providers saw delays in care due to prior
authorizations (PA) and eight in ten said their
patient abandoned treatment while waiting. AHA
also reported 89 percent of hospitals and
healthcare organizations have seen an increase in
denials and 51 percent call this increase
significant. Their research directly indicated
that claims denials and reimbursement delays
stemmed from prior authorization issues. Its
quite common to get your claims denied due to the
absence of prior authorizations and insurance
carriers are not willing to change their
decision. In this article, we shared a few
guidelines which might help you in managing such
denied claims. Common Reasons for Denials Some
of the common reasons your practice might be
receiving denials due to prior authorizations are
as follows Constantly changing payer rules As
mentioned earlier, its quite common for any
insurance carrier to change rules regarding prior
authorizations. Any treatment or medication which
didnt require pre-authorization might need one,
resulting in unexpected denials.
3
Managing Claims Denied Due Absence Of Prior
Authorizations

• New payer contract
• You might recently contract with a new payer,
  unaware of their prior authorization procedures,
  which might result in denial. Other payers may
  not require prior authorization but this new
  payer might require one for the same procedure
  code.
• Absence of eligibility and benefits verification
• Eligibility and benefits verification is the most
  important step of medical billing. The benefits
  report will know if planned services are covered
  by a health plan or if there is a need for prior
  authorization.
• Billers are inexperienced
• It may happen with small practices, where
  providers themselves do all the work of billing
  and coding or assigns billing tasks to the front
  desk person. Payers wont cover the procedure if
  you failed to take prior authorization.
• Managing Denials
• Eligibility and benefits verification
• You must undertake eligibility and benefits
  verification for every single patient visit. It
  will not only help to find out the need for prior
  authorization but also collect the maximum amount
  of patient responsibility. In case the health
  plan is not covering the planned services then
  you can communicate with the patient, give them
  estimates, and also share the mode of payment at
  the time of service.

4
Managing Claims Denied Due Absence Of Prior
Authorizations

• Have patient info, their insurance info, script
  ready with you, call insurance rep, and check the
  requirement of prior authorization. Also keep a
  list of procedure codes ready with your check,
  prior authorization requirement.
• Accurate coding
• Have experienced medical coder in your team,
  double-check CPT codes. Its critical for
  providers to work hand in hand to mitigate
  denials from having an incorrect procedural code
  on the prior authorization. For example, if the
  provider schedules a biopsy that doesnt need
  prior approval but then excises a lesion (needs
  prior approval), the claim for the excision will
  likely be denied. Theres no penalty for
  authorizing a procedure and not completing it, so
  its better to check prior authorization
  requirements with accurate procedure codes.
• Appeal a denial decision
• Never hesitate to appeal a payers decision.
  Phone calls to the health plans medical
  director, while time-consuming, can be extremely
  effective in changing outcomes. Keep your
  documentation accurate and complete. For example,
  if a provider plans to perform a sigmoidoscopy on
  a 45-year-old patient, its critical to include
  the fact that the patients family history
  includes colon cancer in a first-degree relative
  at age 40 on the prior authorization request.
  Dont always consider prior authorization denials
  are hard denials, at least talk to the payer.

5
Managing Claims Denied Due Absence Of Prior
Authorizations
Track every single claim Track every single claim
and categorize submitted claims as paid, pending
status, and denied. Categorize denied claims
payer-wise and denial reason-wise. Tracking
denials by health plan can help your practice
identify trends that uncover coverage positions
on certain procedures and/or improper coding
practices that can be adjusted. Medisys Data
Solutions is a medical billing company providing
complete assistance in revenue cycle operations
including prior authorizations. We are well
versed with payer-wise prior authorization
processes for major insurance carriers. After
completing eligibility and benefits verification
for every patient visit, we update the provider
with any prior authorization requirement. To know
more about our prior authorization services or
specialty wise billing and coding services,
contact us info_at_medisysdata.com/ 302-261-9187
6
(No Transcript)