Avoiding Prior Authorization Denials - PowerPoint PPT Presentation

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Avoiding Prior Authorization Denials

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In this article, we will discuss the top reasons and best practices for avoiding prior authorization denials. – PowerPoint PPT presentation

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Title: Avoiding Prior Authorization Denials


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Avoiding Prior Authorization Denials
  • The burden of Prior Authorization
  • According to a recent survey from the American
    Medical Association (AMA), prior authorization
    creates an administrative burden for healthcare
    practices, negatively impacting providers and
    delaying patient care. The survey also found that
    providers complete an average of 41 prior
    authorizations each week and spend an average of
    two business days on the processes. Forty percent
    of physicians have staff who exclusively complete
    prior authorizations. 88 percent of survey
    respondents reported that prior authorization
    generates a high or extremely high burden. Even
    though providers work hard to reduce prior
    authorization claim denials, insurance carriers
    continue to expand the number of visit types and
    procedures that require prior authorization,
    leading to an upswing in denials. In this
    article, we will discuss the top reasons and best
    practices for avoiding prior authorization
    denials.
  • Reasons for Prior Authorization Denials
  • Providers might be getting enrolled with new
    insurance carriers and every insurance carrier
    has its own set of rules for prior authorization.
    Its obvious to receive prior authorization
    denials with newly added insurance carriers.

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Avoiding Prior Authorization Denials
  • As discussed earlier, insurance carriers change
    billing guidelines unexpectedly. Insurance
    carriers might update their website or provider
    portal with revised guidelines. But is difficult
    for the practice owner to keep track of all
    billing updates. The provider will come to know
    about these billing updates, once their claim/s
    got denied. Once their claim gets denied, it will
    consider a soft denial remedied by resubmitting
    forms in accordance with the insurance carriers
    updated specifications.
  • Another obvious reason for prior authorization
    denial is not having skilled manpower to handle
    prior authorization requests. You need skilled
    manpower to find out prior authorization
    requirements, timely submission of application
    supporting documents, and constant follow-up. As
    mentioned earlier, prior authorization is a very
    time-consuming and tedious process.
  • Best Practices for Avoiding Prior Authorization
    Denials
  • Eligibility and benefits verification Ensure
    that your every visit is checked for patient
    eligibility and insurance coverage. Make it part
    of your revenue cycle process to check whether
    prior authorization is required for any patient
    visit.

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Avoiding Prior Authorization Denials
  • Correct procedure codes Its critical for the
    billing team and physicians 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 (which 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 get prior
    authorization.
  • Denial management Even though you are working
    diligently, expect a few claims are going to get
    denied. As mentioned earlier, insurance carriers
    keep on adding the number of visit types and
    procedures that require prior authorization,
    leading to an upswing in denials. Whenever you
    receive a denial, talk to the insurance rep and
    appeal it with the required documentation asap.
  • Evidence-based clinical guidelines Thorough
    documentation based on a respected clinical
    source is the best way to obtain preauthorization
    or appeal a denial. In addition to government
    sources, it may be worth asking your most
    frequent payers what guidelines they use. Where
    ever applicable, clearly document any deviation
    from evidence-based guidelines. 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 precertification request.

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Avoiding Prior Authorization Denials
  • Many payers require authorization for services
    prior to or within fourteen calendar days of
    services rendered. Requests for approval filed
    after the fact are referred to as retroactive
    authorization and occur typically under
    extenuating circumstances and where provider
    reconsideration requests are required by the
    payer. Similarly, personal injury and hospital
    billers routinely file incomplete claims to meet
    timely filing, knowing they will be denied, and
    knowing they will appeal them later.
  • The most important thing while avoiding prior
    authorization denials is never be afraid to
    appeal a payers decision. Phone calls to
    insurance rep could be time-consuming but can be
    extremely effective in changing outcomes. Or you
    can simply outsource your prior authorization
    requirements to the leading medical billing
    company Medical Billers and Coders (MBC).
  • On average, a practice sends 100 prior
    authorization requests within a month. Your
    billing staff may not have that amount of time
    and specialty-wise expertise but our dedicated
    prior authorization experts do. To know more
    about our prior authorization services, email us
    at info_at_medicalbillersandcoders.com or call
    us 888-357-3226.
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