Role of Prior Authorization in Medical Billing

1
Role of Prior Authorization in
Medical Billing
2
Role of Prior Authorization in Medical Billing

• Defining Prior Authorization
• Under medical and prescription drug plans, some
  treatments and medications may need approval from
  insurance carriers before being delivered care by
  healthcare providers. Prior authorization (or
  pre-authorization) is usually required if the
  patient needs a complex treatment or
  prescription. This list of medical treatments and
  medications is different for every insurance
  carrier. For example, some of the medical
  treatments and medications that may require prior
  authorization are
• Medications that may be unsafe when combined with
  other medications
• Medical treatments that have lower-cost, but
  equally effective, alternatives available
• Medical treatments and medications that should
  only be used for certain health conditions
• Medical treatments and medications that are often
  misused or abused
• Drugs are often used for cosmetic purposes
• As mentioned above, each insurance carrier has a
  different list of medical treatments and
  medications requiring prior authorization.
  Practice owners need to keep a close eye on
  changing prior authorization guidelines. Claims
  rejected due to the absence of prior
  authorizations are considered as hard denials
  i.e., difficult to receive insurance
  reimbursement after claims got denied. Prior
  authorization may be needed before getting
  outpatient services in a hospital or
  hospital-affiliated facility. This place of
  service authorization may help guide providers
  and customers to a more cost-efficient location
  while ensuring the quality of care when the use
  of an outpatient hospital is not medically
  necessary.

3
Role of Prior Authorization in Medical Billing

• Sometimes, patients might need additional
  treatments or prescriptions after their initial
  visit. For such treatments, you need to get a
  medical necessity review, or simply
  authorization from the insurance carrier.
• Key Facts of Prior Authorization
• The prior authorization process gives insurance
  carriers a chance to review how necessary medical
  treatment or medication may be in treating a
  patients condition. For example, some brand-name
  medications are very costly. During the review,
  an insurance carrier may decide a generic or
  another lower-cost alternative may work just as
  well in treating medical conditions.
• Once you send a prior authorization request to an
  insurance carrier, they will either approve it
  deny it ask for additional information or
  recommend an alternative thats less costly, but
  equally effective, before your original request
  is approved. If youre unhappy with your prior
  authorization response, you can ask for a review
  of the decision.
• Prior authorization is not required if the
  patient has an emergency and/or needs emergency
  medication. However, coverage for emergency
  medical costs is subject to the terms of your
  health plan. Insurance carriers generally respond
  within 5 to 10 working days after your prior
  authorization request is submitted.

4
Role of Prior Authorization in Medical Billing
No Surprises Act (NSA) The No Surprises Act was
enacted in 2020 and goes into effect on January
1, 2022. It provides federal consumer protections
against unanticipated out-of-network bills called
surprise bills. Surprise bills arise in
emergencies when patients typically have little
or no say in where they receive care. They also
arise in non-emergencies when patients at
in-network hospitals or facilities receive care
from providers (such as anesthesiologists) who
are not in-network and whom the patient did not
choose. The No Surprises Act (NSA) requires
surprise bills must be covered without prior
authorization and in-network cost sharing must
apply. Ever Increasing Burden of Prior
Authorization Most providers feel that prior
authorizations are too time-consuming and they
distract providers from patient care. Providers
also feel that prior authorization requirements
have increased exponentially and now becoming
burdensome to healthcare practices. Providers do
not appreciate spending time undertaking
administrative tasks like completing prior
authorizations when they are not properly
reimbursed for the time spent or when they do not
have trained staff to expedite the process. The
simplest way to reduce the ever-increasing burden
of prior authorizations is to outsource your
medical billing services to the leading medical
billing company Legion Health Care Solutions. We
are providing complete medical billing and coding
services to healthcare providers of various
medical specialties. Please get in touch with us
in case of any medical billing assistance on
727-475-1834 or email info_at_legionhealthcaresolutio
ns.com
5
(No Transcript)