The 2024 Prior Authorization Process For Medical Providers

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Mastering the 2024 Prior Authorization Process
for Medical Providers

• Presented By
• Toni Elhoms, CCS, CPC, CPMA, CRC, CEMA,
  AHIMA-Approved ICD-10-CM / PCS Trainer

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Toni Elhoms, CCS, CPC, CPMA, CRC, CEMA, AHIMA
Approved ICD-10-CM/PCS Trainer

• CEO Alpha Coding Experts
• Podcast Host Alpha Coding Podcast
• National Speaker - Coding, Compliance and
  Reimbursement SME
• Former President of Orlando, Florida AAPC
  Chapter
• Expert Witness
• Published Author
• Consultant/Educator/Trainer

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Agenda
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2024 Prior Authorizations

• Prior Authorization (PA) process by which a
  physician/QHCP must obtain advanced approval from
  a health plan BEFORE a specific procedure,
  service, device, supply, test, or medication is
  delivered to the patient to qualify for payment
  coverage
• AKA
• Preauthorization
• Precertification
• Prior approval
• Prior notification
• Prospective review
• Prior review

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2024 Prior Authorizations
Source Phoenix Virtual Staff
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Medical Necessity

• There is often a major disconnect between how
  insurance payers interpret and apply medical
  necessity rules and how healthcare providers and
  physicians determine what care/treatment is
  medically necessary
• The disconnect between providers and payers can
  have systemic consequences for patient care and
  healthcare organizations if not carefully and
  strategically addressed
• Conflicts of interest considerations with payer
  cost containment strategies

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2024 Prior Authorizations
Source AMA Prior Authorization Impact -
Physician Survey
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2024 Prior Authorizations
Source AMA Prior Authorization Impact -
Physician Survey
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2024 Prior Authorizations
Source AMA Prior Authorization Impact -
Physician Survey
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CMS-0057-F

• In 2024 CMS introduced a landmark final rule -
  Interoperability and Prior Authorization
  (CMS-0057-F)
• Applies to Medicare Advantage, state Medicaid and
  Childrens Health Insurance Program (CHIP-FFS),
  Medicaid managed care plans, CHIP managed care
  entities, and Qualified Health Plans on the
  Federally Facilitated Exchanges
• Now required to implement and maintain Health
  Level 7 (HL7) application programming interfaces
  (APIs) to improve electronic exchange of data to
  streamline the PA process

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Who is Impacted?
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Workflows Impacted
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Best Practice Tips
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