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Your Questions Answered: Prior Authorizations

This is the second in a series of articles that will answer some commonly asked questions about different aspects of the revenue cycle and practice management.

It is no secret that prior authorizations are crucial to ensuring that your practice has the ability to perform all necessary procedures and tests on a patient—and to be reimbursed for those services. Although the process seems straight forward, it can still have some challenges and quirks that practices should know about. Today, we are answering some of the most commonly asked questions about prior authorizations:

  • How do you handle prior authorizations when the insurance carrier has provided differing opinions on coverage? Receiving conflicting information from a payer can happen and can often create confusion for practices. One of the first steps to avoid this situation is to try to have information in writing about the payer’s medical necessity guidelines. Many companies will publish a list of codes that require prior authorization, so you can use this information as a starting point when determining what needs to be authorized. I suggest using this list of codes along with your practice’s contracts with the payer as leverage to attain the necessary authorizations.
  • In an effort to prevent denials, what is the best way to find out about coordination of benefits or pre-existing conditions prior to a patient appointment? Assuming you have already verified coverage with the patient, often the best starting point is to call the payer. Sometimes insurance companies know if there is another payer for a patient that would be involved in coordinating benefits. However the payer may not be willing to share that information, so you may have to rely on the patient. If you are trying to determine what will be covered for a patient with pre-existing conditions, the first thing to do is confirm what the patient is coming in for. After that, you can reach out to the payer to find out what they will cover—and if there are any pre-existing conditions clauses in the patient’s contract. This is not a true prior authorization, but it will give your practice a good idea about what procedures can be done and be reimbursed for.
  • How do we prevent providers from performing procedures that were not pre-authorized? This is really one of the toughest parts of the job and people have been trying to address it for years. My best piece of advice is education, education, education! If you consistently show the providers how much money they are losing by performing procedures that were not approved, they may start to realize the financial implications of continuing this habit. Overall, it is tough to get providers to understand the ramifications of these actions; even with extensive education some providers will still do whatever they want.

Do you have a practice management question that you would like answered? Leave us a comment or submit an idea in the column box on the right side of the blog and we will answer it in an upcoming post.