Preauthorization is one of the trending terms of the healthcare industry in recent times. This blog gives you a clear picture of prior authorization, why it is essential for RCM, and how to handle PA most effectively in your practice.
What is Prior Authorization in Healthcare?
Even before insurance companies agree to pay for medications or medical equipment, medical providers require a sign of a patient receiving a specific treatment (PA).
Maybe you still have questions such as who uses this PA? To what end do they use it? Doctors do not operate this Prior authorization, health insurance companies to verify that a specific treatment or type of treatment is medically necessary before prescribed.
Prior Authorization in RCM
In revenue cycle management (RCM), prior authorization is essential as payers need to confirm whether a particular pharmaceutical or procedure is approved. Suppose the insurance company does not support some treatments or medical tests. In that case, healthcare providers should wait until approval is obtained, or they should contact insurers for permission and then take the required steps.
A pulmonary expert, for example, may recommend the chest CT scan for a patient, but a heart specialist for the same patient may have already prescribed the same scan before two weeks. Why do you have to wait until your treatments have been approved? Since non-approval after treatment leads to enormous costs for either the patient or the provider of medical services. That not only disturbs RCM function but affects patient care because of the omission of the PA process.
Tips to Make PA More Efficient
Accurate Documentation to Avoid Denials
Because most healthcare providers take most of their precious time, the long prior approval process is not preferred. But the use of PA shortcuts only leads to negative results. It is better to do so for the first time to avoid this type of problem.
Today, there are many new insurance plans and new drugs within PA, and medical professionals can still find it difficult to take further steps. Prior authorization has, therefore, now become an approach that saves money. Many suppliers have also begun moving to electronic PA to manage documents better and save time.
Approved Pre-authorization makes the documentation procedure easy
Some insurance firms have specific treatments and prescriptions approved in advance. This will make it easier to precede the documentation process, resulting in an effective RCM. Sometimes complaints about irrelevant billing costs are received by both the patient and the insurance company in the process of approved preauthorization. The insurance company is not guaranteed and needs to cover 100% of costs.
Therefore, it is recommended that the correct information be provided regarding the fixed amount paid on your visit to a doctor, the initial payment before the pitch of an insurance plan, and the percentage of the patient’s health visit cost.
Patient Role in The Prior Authorization Process
It’s not the health providers and payors who are using the PA process. In the preauthorization process, the patient also plays a key role. Why do they have to share information and understand the criteria for inclusion and exclusion of the payer?
The medical providers should ensure that the patient data are accurately collected before initiating the PA process. That includes full medical history, previous treatment details, conditions, symptoms, diagnosis, and detailed provider notes.
The insurers are not covered for specific concerns and non-emergency therapies, and they are not eligible for PA. Since each insurance company has its own rules for prior authorization, each healthcare provider is responsible, and the patient must check the information in advance.
Use Emerging Technology to Make PA Better
With the start of a profound technological change in the health industry, prior authorization also becomes technological progress. Today, many software applications with access to electronic health records are developed for PA (EHR). This kind of superpower software’s advanced capabilities is to access and sync patient medical records, reduce PA errors, and reduce time and cost authorization processes.
The next big thing to notice is an advanced Electronic Prior Authorization – it is easy to recognize the existing CPT code or HCPCS code. To determine what is needed, gather data from the visit notes, and pre-approval to include diagnostic procedures, the electronic PA matches those codes to the insurance rules. It is therefore recommended that the latest solutions for improved PA be updated and implemented.
Patient health records
The security of privacy and information should be your priority when managing patient health records and the Electronic Health Record (EHR) prior authorization platform. All of this should be safeguarded, such as password control, system access authorization, access controls, WIFI, and physical controls.
In the RCM industry, there are numerous effective ways of improving prior authorization. Regular monitoring of PAs and implementing the latest technological standards for PA procedures, therapies, and medical devices will optimize prior approval.
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