One of the most important and frequently misunderstood processes in healthcare is prior authorization. The purpose of this article is to explain what prior authorization is and how it applies to medical care, particularly prescription drugs and treatments. Here we’ll take a look at the reasoning behind this process, which is mostly about healthcare providers getting clearance from insurance companies before they can treat or prescribe medication to a patient. This article will also provide tips on how it may be improved for increased efficiency.
Understanding Prior Authorization for Medication
Prior authorizations are required in the healthcare industry. Learn more about previous permission and how it works below.
What is Prior Authorization?
In the medical field, “prior authorization” means that your insurance company must give their stamp of approval before any healthcare provider (such a hospital or primary care physician) may treat you or prescribe any prescription.
The idea of prior authorization is to prevent doctors from automatically prescribing the most costly treatment choice when a cheaper one might be just as effective. Specialty pharmaceuticals, MRIs, hefty surgical procedures that may be safely done in an outpatient environment, and other expensive treatments and medications fall into this category.
A physician or pharmacy’s ability to get their money back depends on the health insurance company’s choice to pay for a treatment plan or not. This decision is based on the outcomes of a prior authorization review.
Prior Authorization Process
A patient’s need for surgery, testing, medicine, or equipment is determined at the first stage of prior authorization. The next step is for the doctor to check the health plan’s policy manual or formulary to see if the treatment they’ve prescribed requires prior approval. If a previous permission request is required, the physician must attest to the accuracy of the medical need by filling out and signing the form. Providers can submit claims to insurers or payers without obtaining prior authorization, but this does not ensure that the claims will be approved.
On the other hand, if prior authorization is really necessary, the doctor needs to compile specifics for each applicable CPT code. Prior authorization requests must be accompanied by a particular number, which must be obtained from the payer and included in the final claim submission. Usually, the payer and provider will have to manually complete these steps by exchanging a string of emails, faxes, and phone calls. It is also the provider’s duty to persistently pursue a decision from the insurance company on the prior authorization request, whether it acceptance, rerouting, or rejection. There is typically a lot of inefficiency and lost resources during this stage because it is unplanned and done on the fly.
How Long Do Prior Authorizations Take?
How long it takes for an insurance company to approve a prior authorization request is dependent on a number of factors, such as the nature of the request, the medication or therapy in question, the patient’s location, the severity of their condition, and the volume of requests received by the firm. You should expect to hear back from the insurer within a few days to a few weeks on average. For health plans that are not self-insured and are instead controlled by the state, the regulations regarding prior authorization might differ from one state to another.
A few insurance companies may offer faster services for requests that are very time-sensitive. Decisions in these cases are often reached within a few days or even hours. Find out from your insurance provider the typical processing time for prior authorization requests and whether there are any particular procedures you must adhere to.
How to Speed Up Prior Authorization
The majority of patients are seeing a negative impact on their care due to the lengthy wait for prior authorizations. The timely approval of patient prior authorizations is of the utmost importance, as it ensures that both you and your patients can get the necessary therapy. In order to make the prior authorization procedure easier, consider the following:
Designate the Right Staff Member
Get someone on staff who is a specialist in this field or who has a natural talent for the procedure to head up your practice. Provide them with the resources they claim are necessary to maintain process documentation and payer rule updates. Staff will become more efficient and sensitive to the intricacies of each payer as they handle prior authorization on a daily basis.
Ensure Correct and Complete Patient Information
Incorrect or missing information is a major cause of the lengthy processing time for prior authorizations when dealing with health insurance providers. Pay attention to the tiniest things. Incorrectly entered health ID details (number, name, address, etc.) might cause unnecessary delays or even an immediate rejection.
Create a Masterlist
Take the initiative to compile comprehensive lists of all approved medications and treatments, organized by insurance companies, that need prior permission. The next step is to make sure that all of your doctors are aware of the need to verify prior authorization before they treat patients or send medication orders to the drugstore.
Utilize the online payor interfaces to get prior authorizations. Online authorizations are more than half as quick as phone or fax ones. To save time and ensure accuracy, make use of the number of software programs that may automate the prior permission procedure.
Strengthen Relationships with Insurance Providers
Ensuring a seamless pre authorization procedure requires regular and open contact with the health insurance company. This helps to minimize misunderstandings. They can also take a tour of your office, meet with your doctor, and sit in on a consultation. The insurance company will see this as an effort to earn their confidence and foster a cooperative partnership.
Benefits of Efficient Prior Authorizations
The healthcare sector relies on prior authorization as a crucial mechanism to guarantee that patients receive the prescription and medical services they need. Some advantages of a well-executed prior authorization are as follows:
By quickly and accurately approving prescriptions, efficient prior authorization helps keep drug costs down while still meeting patients’ needs. Payers can cut down on processing expenses, while providers can save money on staff time, paper, and postage.
Providers are able to give patients a more seamless clinical and financial experience by streamlining their operations. When patients can observe that their accounts are being processed with care and speed, they are less likely to experience frustration due to fewer delays and mistakes. Furthermore, patients are able to focus on their treatment plan adherence when they know their care will be reimbursed, rather than fretting over the timing or method of payment.
When a payer has an effective prior authorization procedure, it eliminates the need for specialized personnel to spend countless hours searching for the information they require online or over the phone. Their ability to concentrate on giving their patients high-quality care would be greatly enhanced by this.
Reducing denials—which cost providers billions annually—is another benefit of streamlining the prior authorization procedure. This means less bad debt and write-offs for providers, hence they won’t have to spend as much time chasing after money.
Simplify Your Prior Authorization Process with VISAYA KPO
Nowadays, it’s crucial to know how to handle prior permission in the healthcare industry. This procedure is essential for making sure patients get therapies that are both needed and affordable, but it may be tedious at times. Healthcare providers may improve care outcomes and patient satisfaction while saving time and money by simplifying this process.
Do you want to make pre authorization easier for your healthcare practice? As an industry-leading outsourced provider of healthcare management solutions, VISAYA KPO is your best bet. Prior authorizations are complex processes, but with the help of VISAYA KPO, you may outsource this administrative work and devote more time to patient care. Accuracy, speed, and conformity with insurance standards are hallmarks of the prior authorization procedure, which our expert team can manage with ease.