Are You Making These 4 Mistakes in Prior Authorization?

Outsourcing Prior AuthorizationThe advent of new regulations & consequent amendments with the demystification of medical science is impacting the business cycle of healthcare providers. It is important to note that technology advancements are also having a significant influence on the operational practices on a day to day basis.

♦ While an involvement of practice management in Prior Authorization isn’t a new phenomenon, its effective management seems to be a challenge with majority practices at large.

♦ They often lack the in-house expertise to maintain a balance between financial well-being & a patient –centric model. We find a huge amount of money being spent by the providers these days to arrive at a streamlined consistency in their pre-authorization process.

♦ However, the implementation leaves a lot to be desired with a lackluster approach that diminishes any possibilities of the right checks & balances in the benefits verification needs.

Pre-certification priorities can be a challenge for businesses as an understanding of the claims adjudication methodology of the insurers is often not up to the required standards. Pre-notification services demand specialized skill-set that has to be nurtured with discipline.

♦ Today, we find numerous third party vendors providing services in authorization domain precisely due to the real-time needs of bringing about viability in the entire prior authorization process with distinction. Some of the common pitfalls that can be detrimental during verification services are :

Lack of payor’s claims evaluation priorities: Most of the practices lack the centralized structure that can give them automated updates about new alterations or a comprehensive understanding of specific insurer’s guidelines. Their authorization does not follow the prerequisites & as such prompt feedbacks get negated leading to errors in the entire denial management process.

The whimsical approach in follow-ups: Often it is seen that follow-ups with the concerned insurance groups with the necessary changes that will facilitate a better receipt aren’t up to the mark. Your employees lack the skill-set or intuition to determine the right changes that will bring about a consolidated response on a quick TAT.

Lack of specialization: As discussed earlier, your team whose primarily role is to serve the patients do not have the necessary understanding about the prescribed form of drugs, medicines for a particular form of treatment as advised by the health care insurers.

HIPAA compliance: Management of information of patients in a sensitive manner is a top priority during authorization. The absence of best practices during verification can make your task of eligibility verification all the more hectic!


Leave a Reply

Your email address will not be published. Required fields are marked *