A Detailed Guide On Prior Authorization Process In RCM

1
A Detailed Guide On Prior Authorization
Process In RCM
2
A Detailed Guide On Prior Authorization Process
In RCM
In no small measure, the difficulty of providing
patients with the proper care at the appropriate
time has skyrocketed up the graph, and the
conflict between cost-conscious insurance
companies, patients, and their doctors wont go
away any time soon. Sounds like a dilemma? We all
can agree to the stemmed fact that finding
innovative ways to improve care delivery has been
a goal for many healthcare executives as the
healthcare landscape continues to get more
complex. Heres food for thought! Even though
youve reviewed your processes, improved the
workflow, and trained your team, your revenue
still doesnt correspond to the number of doctors
or the amount of hours they devote to patient
care. What is happening? Where are the losses and
income leakage that you cant identify? Lets
talk facts shall we? Prior authorization requires
a lot of expertise and guidance to get it right.
Thus, resorting to an in-house team is not a fine
option. Prior authorization management is a
crucial component of revenue cycle management and
thus needs to be handled by the experts of the
healthcare industry. To demonstrate to the
insurance company why a particular medical
treatment, equipment, or medicine that has been
prescribed is required, a healthcare professional
must complete a PA form as part of the PA
process. The necessity and significance of the
Prior Authorization Process are discussed in this
article.
3
A Detailed Guide On Prior Authorization Process
In RCM
What Exactly Is Prior Authorization? Before a
certain treatment, service, gadget, or drug is
given to the patient in order to qualify for
coverage, doctors and other healthcare
professionals must acquire in advance approval
from a health insurance plan (known as a prior
authorization or PA) process. How Does the
Need for Medical Care Affect Pre-Authorization?
The hospital must decide whether to absorb the
expense or charge the patients when health care
providers are unable to obtain the required
clearances and the payer (insurance company)
denies the concerned payment. Procedures not
covered by the patients health plan are
explicitly defined and noted during the
verification process. The patient is liable for
paying for any services rendered when they obtain
benefits or treatments that are not covered by
their insurance plan. However, when claims are
rejected owing to the providers failure to
obtain authorization, they must bear the expense
themselves, which results in a financial loss
that affects the entire revenue cycle. In some
circumstances, the patient receives a bill for
the unpaid amount, and they are then responsible
for paying it. However, doing so would be wrong
and would harm the hospitals standing.
Therefore, getting pre-authorization at the
appropriate time is crucial to getting paid for
the treatments provided.
4
A Detailed Guide On Prior Authorization Process
In RCM
Healthcare organizations can streamline the prior
authorization process and lighten the load on
staff and clinicians by following these best
practices. These actions also lessen the risk of
denials, operational stumbling blocks, and
patient care delays. Lets take a look at
significant pointers that streamline the prior
authorization process, shall we? 1. Accurate
Records to Prevent Rejections The lengthy prior
authorization process wont be preferred by the
majority of healthcare practitioners because it
takes up so much of their valuable time. However,
cutting corners with PA processes will only
result in rejections. Things are preferable to
get it correctly the first time in order to avoid
problems of this nature. Even if there are a lot
of new insurance plans available today and more
pharmaceuticals are falling under the PA
umbrella, healthcare providers may still find it
difficult to go forward. Therefore, prior
authorization is now a cost-effective strategy.
To better handle documentation and save time,
many providers have started switching to
electronic PA. 2. Pre-authorization that has
been approved makes the documentation process
simple Some insurance providers do pre-approved
particular medications and treatments. In such
circumstances, the documentation process becomes
simpler to initiate, leading to effective RCM.
Pre-authorization that has been issued has
occasionally been the subject of complaints from
both the patient and the insurance provider
regarding unnecessary billing costs.
5
A Detailed Guide On Prior Authorization Process
In RCM
It is advised to give the right information
regarding the set amount payable during the
medical visit, the initial amount payable before
the insurance plan kicks in, and a percentage of
the patients share of the costs associated with
the appointment. 3. The Part Played By Patients
In The Prior Authorization Process The PA
procedure is not for payers and healthcare
providers. In the pre-authorization procedure,
the patient is also crucial. Why? Because they
must exchange information and comprehend the
payers inclusion and exclusion
requirements. Healthcare professionals should
make sure that the following patient data is
appropriately obtained before starting the PA
process. This information covers the patients
whole medical history, past treatments, ailments,
symptoms, and diagnoses, as well as in-depth
physician notes. 4. Improve PA With Emerging
Technology Prior Authorization is being
translated into technical breakthroughs as the
healthcare business began to experience a
significant technological revolution. Numerous
software programs are being created today that
allow access to electronic health records and
perform PA (EHR). This type of healthcare
software has the sophisticated capabilities to
access and synchronize patient medical records,
reducing PA errors, the time and financial
expenses associated with the permission procedure.
6
A Detailed Guide On Prior Authorization Process
In RCM

• 5. Protect patient health information and PA
• When handling patient health records and prior
  authorization on an electronic health record
  (EHR) platform, privacy and information security
  should be your top priorities. Everything should
  be kept safe, including wireless and physical
  restrictions, access authorization to the system,
  password controls, and access controls.
• Preauthorization is a complicated process for a
  number of reasons. These consist of
• Each payer has different and numerous
  requirements, which causes mistakes and delays.
• Workflows between payers and providers are
  inconsistent.
• Rules for payers are not uniform and it is
  continually evolving.
• Providers cannot constantly review and update
  payer rules.
• Payers continue to add to current health plans to
  grow their company.
• Errors occur when previous auth requests are
  manually entered.
• Lack of skilled personnel results in mistakes
  that cause delays.
• Stress at work causes medical mistakes.
• Preauthorization Benefits of Automation
• Speed up the process for obtaining prior
  authorizations.
• Less administrative and medical work is required
• Insights into the permission status of real-time
  data

7
A Detailed Guide On Prior Authorization Process
In RCM

• Accelerate the delivery of patient treatment
• Reduce denials and monitor the frequency of
  non-payment
• Improve first submission success to decrease AR
  backlog and increase cash inflow
• Increasing income by being fully reimbursed for
  all services rendered
• Boost general practice output.
• Wrapping Up
• Prior permission work is less of a strain on
  staff, and it takes up less of their time. Strong
  patient satisfaction, simplified prior
  authorizations, and quicker scheduling have
  helped scores of medical settings make up lost
  revenue and boost their bottom line financially.
  If youre looking for the perfect partner to take
  over the complexities of the process, Medisys
  Data Solutions is merely one tap away!

8
(No Transcript)