Revenue cycle management services include multiple process steps that start from documentation and end with successful reimbursement and payment posting. One of the small yet very significant steps in this is prior authorization.
In this article, we will discuss what prior authorization is and how significant it is revenue cycle management services. We’ll also talk about the importance of having expert RCM service providers handle prior authorization requests and the benefit of that.
What is prior authorization?
Prior authorization is the process of getting prior approval or consent from the payer (insurance provider) for the prescription, test, or procedure that the patient may need in addition to the ‘allowed’ services.
Every insurance policy has its own terms of what’s included and not included. Let’s say a practitioner wants a patient to get a mammogram done for an abnormal clot identified, even though the patient’s yearly mammogram tests are done with.
In this case, the revenue cycle management service experts would receive a red flag while trying to add the mammogram service. The experts will need to identify why there is a flag and then get back to the insurance company to get the process approved.
Prior authorization steps
The following are some of the common steps followed for prior authorization.
1. The revenue cycle management service team receives a red flag and realizes they may not be able to bill for a particular service without prior authorization.
2. The patient is informed of the same, and the team cross-verifies the coverage details.
3. The team reaches out to the payer to confirm the need for prior authorization and ask for relevant details.
4. The team collects all necessary documents, and the doctor notes why the particular service is needed and forwards them to the payer.
5. It may take up to 10 working days for the request to be approved. Most times, the payers get back with further questions, and this can stall the approval process.
Though this sounds straightforward, prior authorization is one of the challenging scopes of revenue cycle management services because each case would be different. The team would have to decide on the spot on what the right approach is and need to be constantly active to close prior authorization requests.
Conclusion
If the prior authorization request is approved, the physicians can go ahead with the right service. If not, the revenue cycle management service team may have to decide how they want to appeal. The denial could be due to errors in paperwork, incomplete documentation, or lack of valid reason.
Last year, 94% of physicians mentioned that there was some delay in diagnoses and treatments due to prior authorization issues. Having a reliable revenue cycle management service team in place can help avoid these delays and ensure patients get the service they need quickly. The use of technology in automating some of the steps of prior authorization quickens the process and brings down the work load of the RCM experts.
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