Medical Billing Prior Authorization
In medical billing, authorization refers to the process by which the payer agrees to cover the prescribed services before they are performed. Pre-authorization or prior authorization services are other terms used for authorization. It is a mandatory requirement to ensure that the insurance payer pays for the medical services listed on the medical claim form. Without proper authorization, the insurance payer can refuse payment of a patient’s healthcare treatment as part of the health care insurance policy.
The healthcare practices are responsible for obtaining authorization for the medical procedure. Before performing the procedure, the provider must apply for authorization. Once approved, the payer issues an authorization number to the health care provider for future reference. Certain procedures necessitate pre-authorization from the insurance company.
Authorization is based on the patient’s insurance plan. Insurance companies pre-authorize requests based on benefit terms and required medical treatments. The insurance provider issues a pre-authorization number, which must be quoted on the final claim form and submitted after the treatment.
Prior Authorization Submission Requests
Authorization requests can be submitted both manually and electronically by the healthcare professional. Offline and online forms are available for submitting a written authorization request, and an electronic authorization request is submitted via fax or mail.
Insurance companies have different specifications for authorization requests. However, when filing authorization requests, the following information remains consistent.
- Demographic information about the patient (name, date of birth, insurance ID number, etc.) throughout the insurance verification procedure
- Provider Specifications (both referring and servicing provider)
- Address, Tax ID, National Provider Identifier (NPI), Phone and fax numbers
- The requested procedure with appropriate CPT/HCPCS codes
- The diagnosis (corresponding ICD code and description)
- In the case of inpatient requests, recommended length of hospital stay
Also, the payer may request additional documents based on their needs.
What Are Prior Authorization Services?
Pre-authorization in medical billing facilitates hassle-free bill payment. Prior Authorization is essential to medical diagnosis and procedures, particularly when an insurance company resolves claims. It is the process of obtaining insurance carrier authorization to classify specific services. Getting approval from the payer ahead of time improves the claims settlement and reimbursement rate. The procedure involves obtaining an authorization number, which must be included in the claim during submission.
Some of the best practices in pre-authorization services to ensure a smooth procedure are:
- Conducting a comprehensive verification process to determine the services covered to obtain pre-authorization.
- Keeping complete documentation and a record of all relevant information.
- Maintain cordial relations with insurance companies.
- Clarifying the contract terms and processes of various insurance providers, as well as complying with their rules to prevent issues and denial.
- Using benchmark templates to avoid duplicate paperwork and human errors.
- Providing staff with the necessary training for all required procedures.
Advantages of Outsourcing Your Pre Authorization Process
According to the American Medical Association, Prior Authorization (PA) is the procedure by which health care providers must get advance approval from a health insurance plan before delivering a particular process, service, device, supply, or medication to the patient for coverage. You will be given a pre-authorization number once you have obtained pre-authorization from a payer.
To prevent unnecessary denials, include this number in your claims. If your claims are denied due to lack of medical reason, include this pre-authorization number in your appeal letter. Errors in prior authorizations can cause treatment to be delayed and patients to discontinue treatment. Most practitioners have also had procedure requests rejected during the authorization process. This is why outsourcing the prior authorization tasks to quality pre-authorization companies is a good idea.
Insurers may refuse to confirm treatments for the following reasons:
- Insufficient documents or incomplete patient information.
- Medical reasons, such as procedures considered irrelevant or too costly by the insurer.
Why Choose I-Med Claims for Pre-Authorization Services
Each insurance plan establishes a list of covered services, and most PPO (preferred provider organization) benefit plans require pre-certification for inpatient hospital admissions, and many of them require pre-certification for organized healthcare. Other services that typically necessitate pre-authorization include:
- CT and CTA scans
- PET scanning
- Durable Medical Equipment (DME)
Keeping these in mind, we at I-Med Claims help you accelerate your growth with a smooth revenue cycle. Here’s how we can speed up your processes:
We Examine the accuracy: We always double-check the necessary prior authorization requirements. That is to ensure that there are no delays in filling prescriptions, claim refusals or payments lost due to a lack of prior authorization necessities.
We aim to Standardize to save time on the PA process: Our practice to establish a normal procedure for consistently recording data required for prior authorization significantly reduces the time spent on the Authorization.
Constant follow-up: We Follow up on prior authorization requests regularly to avoid delays.
Preparing an Appeal: We prepare an appeal with supporting medical records in case of denied prior authorization.
99% Claim Reimbursement Rate: With a 99% claim rate, we ensure that you have negligible claim denials.