Tips To Handle Prior Authorization in RCM

Handle Prior Authorization in RCM

There was a time when the healthcare industry experienced the surging trend of a term known as Prior Authorization which was also referred to as pre-certification. In the article today, we’ll discuss the importance of prior authorization and its importance in revenue cycle management company. Plus, you will also get an idea about handling Prior authorization in your medical practice. 

Prior Authorization in healthcare

Healthcare providers obtain a sign-off from the insurance companies before treating any patient prioritizing the treatments prescribed to patients. It is called prior authorization. (PA). 

Does it necessary for the healthcare providers to make PA? The answer is simple. Not the doctors but the insurance companies verify the necessity of the treatment raised b the doctors or the healthcare providers for the patient. In order to confirm whether the prescribed treatment is necessary for the patient or the drug advised is required before the treatment.

Prior authorization in the revenue management cycle 

When there’s an approval involved in the process, it gets tricky and gains importance in itself. Prior Authorization plays an important part in verifying the need for a patient’s treatment before it even starts. 

If the insurance companies refuse to approve the underlying medical equipment or the treatment for the patient, healthcare providers must wait till the treatment gets approved or they make arrangements to convince the insurance companies of the necessity treamtment or equipment or get approval to make the necessary steps. 

For instance, ifs a patient neds a CT scan for his chest, but the same prescribed scan has been processed two weeks ago, the insurer might refuse the requisition from processing the same scan again. Until it gets clear that the scan is reviewed and the doctors need to review the medical changes in the heart after medication or treatment, which is given two weeks before, and there’s an actual need for the scan. 

It is necessary to get approval from the insurer for the treatment or any test because if the treatment is refused, there would be a huge bill for the patient or for the healthcare providers at the end of the treatment. Therefore, the approval of the Prior Authorization system affects not only the patient or the healthcare provider but the revenue management system of the practice as well. 

How can you make your Prior authorization effective? 

  1. Avoiding denials by accurate documentation 

Due to the lengthy process of the prior authorization documenting and updating the information of the patients, many times healthcare providers avoid going through PA. Taking shortcuts, not only increases the chances of denials but causes issues in minor things that can be avoided I they were prioritized for the first time. 

Although with the passing years, there are upgrades to the system have been performed, many healthcare providers still find it challenging to keep up with the PA system. Although PA is considered a cost and time-saving approach that can be obtained by just moving through electronic mediums of submitting PA settings and minimizing refusals.  

  1. Approved pre-authorization makes the process easier 

Sometimes, insurance companies approve treatments and equipment before the PA process, which means the RCM process is easy to navigate. As a result, an effective revenue management documentation process is projected. Oftentimes, the pre-approved pre-authorization process gets complaints of useless or irrelevant billings for the treatment from both the patient and the insurance companies. Also, this is not necessary that the insurance companies will bear the full cost of treatment. 

For this, it is important to get complete information and provide accurate details while checking in or out of a doctor’s clinic. This helps in accurate billing, pitching the right insurance plan you have, and a percentage of payable cost by a patient and the insurance company. 

  1. Role of a patient in the PS process 

A pre-authorization process I not only for the healthcare providers and the insurance companies only, for the patients as well. This is because they have to share the accurate data and the information required by the healthcare providers to understand the percentage, amount payable degrees, and the payment criteria of the insurance companies or the bill payer. 

Healthcare providers should ensure before billing that the data and documents provided by the patient are accurate. This data includes the patient’s medical history, symptoms, progressing conditions, previous treatment details, diagnosis, and the previous doctor’s notes and prescriptions. 

In addition, if a patient needs emergency treatment may not be catered by the insurance companies before PA. However, it is the duty of the healthcare provider and the patient to cross-check the data and information before billing the payable cost as every insurance company has its own set of rules to follow. 

  1. Secure health records of patients for PA 

When you are using Electronic health records software and platforms for quick and accurate billing for managing your RCM, the security, and privacy of patients’ information, records, and history should be your priority. System access, password controls, wireless or physical controls of the platform permissions, and access must only be given to the hospital staff or concerned persons. Regardless of the urgency, the information must be secured professionally. 

Final thoughts 

There can be many ways by which RCM systems can be secured. In addition, plenty of effective procedures are there to improve PA in the healthcare industry. First and foremost is the adoption o the latest technology that helps automate and optimize the pre-authorization process. 

At SybridMD, our experts have powerful access to advanced and approved software tools that make the pre-authorization documenting easier and faster. Additionally, with the automated system, it is even easier and quicker to get the billing statements according to updated patient data which often hinders the revenue cycle management. Contact our well-experienced teams today and get the documentation done in no time without the fear of denials.

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