“Revenue Cycle Management Services can shape the future of healthcare practices towards financial stability and operational efficiency”
Even before a healthcare provider offers services, he must go through a necessary step in the medical billing process. This step is known as pre-authorization or prior authorization.
The importance of this step is reflected in the consequences of failing to perform it. As it is a significant part of medical billing operations, not meeting this requirement later leads to revenue leakage.
So, under pre-authorization, healthcare providers must get approval from the insurance company before rendering any medical services. This is to confirm if the patient has needed insurance support or not. This step is a confirmation for the insurance company too, because it learns the patient's medical necessity.
This blog brings attention to this essential step and defines different requirements, importance and how healthcare providers should deal with it.
Pre-authorization – A Need for Robust Revenue Cycle Management
Pre-authorization is a significant step in medical billing for healthcare providers and practices.
When it comes to boosting the revenue cycle, a step like this can make all the difference.
The omission of pre-authorization can be a hassle in achieving adequate reimbursement.
That is why it is vital to check with the insurance provider beforehand. Neglecting this step is not advisable to healthcare providers. Also, this is one of the complexities that make medical billing and coding challenging.
To counter this, healthcare providers can partner with medical billing services and choose revenue cycle management services
Otherwise, at the time of seeking approval, if the insurance company denies treatment, then healthcare providers must not move further until they get the approval.
This is the right way to deal with such situations. Moving ahead with no prior authorization can lead to a disturbed treatment process, inadequate patient data and documentation.
Vital Stages to Achieve Pre-Authorization
Pre-authorization is one of the initial steps in medical billing and coding. As the patient enters the healthcare facility, immediately the process of insurance verification starts.
At this point, healthcare providers check insurance coverage, determine financial responsibility, and figure out missing details.
After the details are recorded, the next step is taking prior approval from the insurance company. So, the administrative staff sends the details to the insurance company to acquire a pre-authorization code.
When this is done, acquired codes are sent to the healthcare provider with confirmation. Now, healthcare providers can start the treatment of their respective patient.
This is an intricate process, and it flows step by step and every step is equally important.
Step-by-Step Breakdown of Pre-Authorization
- There are two types of authorization, the first one must be taken at the beginning. When the patient enters, healthcare providers share their details with the insurance company and get basic authorization to start the treatment.
- Once the healthcare providers examine the patient and determine a further action plan, authorization must be retaken. This approval is for upcoming visits that the patient needs. The insurance company analyzes the medical necessity at this point to give authorization.
- Under pre-authorization, there is a need for an exact follow-up timeline and treatment schedules from both sides (the insurance company and the healthcare provider).
The whole process works in a cycle where healthcare providers send confirmation emails to the insurance company after 5 days and after 10 days asking for authorization. Failure to receive it even after 13 days results in termination of services. - Healthcare providers can make a habit of sending pre-authorization requests weekly. This will simplify the process and increase the chances of achieving approval.
This back and forth between healthcare providers and insurance companies is cumbersome and that is why healthcare providers seek revenue cycle management services for their medical billing operations.
Dealing with such a process is beneficial for the profitability of the healthcare practice.
Let's learn about the advantages in brief:
Key Merits of Pre-Authorization
- Reduction in denial of claims and increase in revenue
- Clarity in patient responsibility to patients and healthcare providers
- Increased accountability and cost efficiency
How To Streamline Pre-Authorization
Some simple tips can save healthcare providers from facing disapproval. These will decrease the drawbacks and make the entire step effortless.
This is how healthcare providers can streamline pre-authorization:
- Always provide correct, error-free documentation and follow up regularly for seamless authorization.
- In the case of emergencies, communicate the same with the insurance company.
- Healthcare providers and patients must check in with the insurance company frequently.
- Coordinate the pre-registration process and pre-authorization process so that there is no need to combine patient information. Together, both processes will get aligned.
- Focus on selecting the right CPT codes for pre-authorization.
All this is essential to streamline revenue cycle management and medical billing services can carry out these crucial tips seamlessly.
Consequences of Not Attaining Pre-authorization
When pre-authorization is not granted, payer policies decide the payment responsibility and it can either be on the healthcare provider or the patient.
In case a patient gets surgery without approval, at certain times the payer refuses to compensate for the services.
On the other hand, insurance companies maintain a list of excluded medicines and procedures for pre-authorization.
That is why some patients don’t receive treatment due to a lack of pre-authorization. To counter this, patients change their treatment plan which is different from what was previously suggested.
Having an insurance plan is not enough to receive treatment, patients must know the excluded and included services.
It is clear that both patients and healthcare providers suffer the consequences of not attaining pre-authorization.
Closing Remarks
Pre-authorization is significant to medical billing operations and healthcare providers need to execute it to maximize revenue. However, just following the process is not enough, it must be done with efficiency as well.
The burden of medical billing and coding can be stressful for healthcare providers, and it can hamper this step in the process. However, revenue cycle management services are a great option to shift it and enhance operational productivity.
Healthcare providers seeking revenue cycle management services have many options, but one company offering appropriate medical billing services is Unify Healthcare Services.
Unify Healthcare Services takes every step in the medical billing and coding process seriously and follows all the steps with precision. We work with an expert team of coders and billers who are well-versed in pre-authorization.
Outsource medical billing services from Unify Healthcare Services to maximize revenue and improve the overall workflow.
