Mastering Prior Authorization in Healthcare: An Overview and Step-by-Step Process

Prior authorization is the most important process in healthcare RCM. Due to errors in prior authorization, claims over $21 million were denied, while that of $291k was written off. It is important to get prior permission from payers to collect payment for the services offered as a healthcare treatment to the patients. Insurance payers might not approve some tests or treatments; practices must wait until they get permission or inform the patients about the costs. 

Prior authorization (PA) is a long process that requires the collaboration and involvement of patients, payers, and healthcare providers. This blog will help you understand the prior authorization process and the steps involved in it. 

Explain prior authorization

It is a process followed by insurance providers to check if the suggested medical procedures, tests, or treatments are necessary for that medical condition. Insurance payers reject reimbursements if a healthcare provider fails to take prior authorization.  

Insurance payers suggest healthcare providers offer less expensive treatments to patients wherever possible. Practices should consider less expensive drugs before going with an expensive one. It completely depends on the insurance company to accept or reject a particular process. 

What does a prior authorization check?

• Drug or service is necessary. 
• Are the same services suggested more than once?
• Are the services beneficial to patients?
• Do the services make sense based on the cost?

Ways to do prior authorization

Healthcare providers should be in-network with the payer to get authorization. Practices should thoroughly verify patient documents and take authorization before starting treatment. Healthcare providers' staff should connect with payers and give all the patient details before admitting them. 

Prior authorization steps

• Determine if the treatment or service requires prior authorization.
• Identify the responsible party for locating patient plan data and managing benefits.
• Understand the process of submitting patient data, as each payer has different rules.
• Ensure proper transmission of service and patient data.
• Await the payer's response and provide follow-up data if necessary.
• Communicate pre-authorization results to the team and patients.
• Take necessary steps to reattempt denied authorizations

Ways to handle prior authorization denials

Medical billers and coders strive to provide the best services and submit clean claims, but insurance companies keep changing their authorization rules resulting in denials. 

Prior authorization denials can be expensive, and healthcare providers should handle them as a priority. Insurance companies ask for prior authorization before healthcare providers start giving services to patients. Here are the top ways to handle prior authorization denials:

 

• Know the right time to appeal
• Stay prepared for denials
• Check for all medical codes
• Strictly follow all the payer guidelines

Common prior authorization hurdles 

Prior authorization is a complex process. Healthcare providers need to follow all the processes to streamline the complete process. To streamline the process, you should first know the prior authorization hurdles: 

• Management of cost
• The necessity of the treatment
• Administrative mistakes
• Unfilled details
• Procedural errors
• Proper steps not followed

How to minimize prior authorization delays 

Prior authorization is a lengthy and time-consuming process. Due to limited time and resources, healthcare providers delay prior authorization resulting in lost revenue. Prior authorization delay also hampers patient care. Here are the most effective ways to minimize prior authorization delays.

• Search for effective low-priced drugs
• Prescribe drugs that do not need authorization
• List down the treatments that do not require authorization
• Follow guidelines
• Educate staff
• Have a prior authorization team
• Use cutting-edge technologies
• Have a robust denial management system  

Do you have sufficient time and staff to take prior authorization for each patient? If not, connect with Plutus Health. With 15+ years of experience in providing end-to-end RCM services, Plutus Health has seamlessly helped all its clients to achieve their desired results. Our prior authorization team ensures all the documents are collected on time and takes authorization before you give services to the patients. 

Do you want to know more about Plutus Health's prior authorization process, explore this blog:

https://www.plutushealthinc.com/post/prior-authorization-in-healthcare-overview-purpose-process