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Moving Beyond “Please” – Streamlining Workflow for Pre-authorizations and Pre-certifications

There is a saying that it’s better to ask for forgiveness than permission. While this approach may be appropriate in some situations, it is not a good idea when it comes to pre-authorizations and pre-certifications. Insurance companies require these permissions to verify that patients are eligible to receive certain services and that those services are absolutely necessary for patient care. Without them, your practice may not be paid for services rendered, leaving you short on critical revenue. Having well-defined processes for pre-authorizations and pre-certifications ensures you receive full payment for the services you provide, minimizing denials and boosting cash flow.

Different Terms, Different Meanings

While many people use the terms interchangeably, there are some key differences between pre-authorizations and pre-certifications. A pre-authorization is needed to check whether a particular kind of service is eligible for payment under the patient’s insurance contract. This type of verification can also determine whether a patient has sufficient benefit dollars to pay for services. For example, if there is a limit to the number of times a patient may visit a certain specialist and the patient has reached that limit, a pre-authorization will tell your practice that no more visits are permissible. Often times, pre-authorizations can be granted retroactively—for example, a practice may have 24 hours to notify a payer after rendering services.

Unlike pre-authorizations, pre-certifications cannot be done retroactively. For these permissions, the payer reviews the medical necessity of a proposed service and provides a certification number to the practice. The practice must include this number on the claim in order to be paid. This type of permission is often required for elective surgeries.

Streamlining Workflow

While there are many ways to enhance your work processes related to pre-authorizations and pre-certifications, there are a few tips I always found helpful:

  • Designate a point person. It can be helpful to have one or two front-end staff responsible for obtaining pre-authorizations and pre-certifications. This individual can partner with nurses and physicians to identify procedures requiring permission, create processes for reliably obtaining that permission and support timely and accurate permission requests.
  • Create a list of procedure codes needing pre-authorization or pre-certification. This list can be paper or electronic, depending on what works best for your practice. It may be wise to sort this list by payer and/or procedure, so practice staff can quickly see which payers require pre-authorizations and pre-certifications for various procedures. A designated point person should update this list regularly to ensure it captures all the current requirements.
  • Get clinicians involved. In some cases, it may be necessary for a provider to speak directly with the insurance company—usually with the medical director—about the medical necessity of a procedure. Clinicians should be prepared to have these conversations and understand their importance.
  • Be proactive. Ideally, if a practice knows the nature of a patient’s appointment before he or she comes into the office, staff can obtain pre-authorizations and pre-certifications upfront. As much as you can handle permissions proactively the better. Otherwise you may be in a situation where you are trying to get paid by managing a denial, which can be a much more difficult process.

Again while these were helpful points when I worked in a practice, every practice is different. What strategies did your organization take to effectively manage pre-authorizations and pre-certifications?