Strategies to maximize the effectiveness of Prior Authorizations

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• Strategies to maximize the effectiveness of Prior
  Authorizations

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Strategies to maximize the effectiveness of Prior
Authorizations
Using automated systems, proactive checks, and
expert and dedicated staff are three ways that
providers can reduce the bad effects of prior
authorizations. Prior authorization is a
strategy that payers use to control cost and
ensure that their insured members receive
medically necessary care. Advance approval from
payers is required to deliver specific services
or items for a patient. Payers use this prior
authorizations increasingly to lower their costs
and deliver quality care to their members. But
this process of getting prior approval for
services creates extra burden for
providers. Automate Prior Authorization According
to the Council for Affordable Quality
Healthcare, Inc. (CAQH) reports Prior
authorization automation process is significantly
lagging compared to other claims management
processes. Switching to automated prior approval
can streamline the process and prevent errors.
Fully electronic prior authorizations can also
save providers time and money. Implementing
prior authorization solutions now will allow
providers to see immediate financial and clinical
benefits while the technology continues to evolve
and stakeholders adopt national standards.
Medical Billing Services in Oregon
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Strategies to maximize the effectiveness of Prior
Authorizations
Proactively check all requirements Providers
agree that prior authorizations can delay patient
access to care. They often have to wait until the
payer receives and approves requests before
starting treatment. Payers can also deny services
or medications, forcing providers to spend time
and resources submitting additional documentation
or an appeal. Providers cannot control payer
decisions on prior authorizations. Approval may
delay the treatment. But providers can implement
a proactive strategy to avoid delays in
care. Check prior authorization requirements
prior to furnishing services or sending
prescriptions to a pharmacy, the AMA
advises. Making sure a prior approval is needed
and what is needed for payer approval can prevent
medical service claim denials and lost
payments. The AMA suggests that providers
monitor payer newsletters, bulletins, and
websites for prior authorization changes or
updates. Providers should also check with payers
at the time of ordering through a standard
electronic eligibility request via the practice
management system or by calling the health
plan.
Medical Billing Services in Oregon
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Strategies to maximize the effectiveness of Prior
Authorizations
Dedicated Staff to check prior authorizations You
can create master lists of medications and
procedures that require prior authorization,
broken down by insurer. If possible, have your
staff use these lists to program your electronic
health record to alert you when you order
something that requires prior authorization or
you can outsource your prior authorization
process to Medisys. We have trained and certified
staff. Providers should be reviewing
requirements regularly, assigning prior
authorizations to a staff member, and using
technology to prevent major pain points as the
industry refines its use of the cost-control
strategy.
Medical Billing Services in Oregon