If you’ve managed a medical practice for any length of time, you’ve likely run into your fair share of eligibility and prior authorization challenges. Before we jump into tactics, tricks, and best practices for helping you tackle prior authorization, let’s take a quick step back and review the basics…
What is Prior Authorization?
Prior authorization refers to the eligibility verification process that allows practices to submit and recoup on approved claims to optimize cash flow. Poor prior authorization processes can lead to the exact opposite of what you want – increased denials and decreased revenue. This article will provide you with ways to reinvent or overhaul your eligibility verification process to give you the most successful outcomes for both practice efficiency and profit. Denials shouldn’t be a regular part of your practice’s operations. Why are you settling for less-than-ideal authorization practices? Use this article as the first step in committing your practice to advanced eligibility policies.
Place priority on front office operations
Your administrative and billing teams are your first lines of defense against denied claims. Eligibility verification is much more than merely collecting and recording the right insurance information. While this step is necessary, it’s only one piece of the puzzle. Enhancing the eligibility process means digging deeper to discover whether the patient has met the plan deductible, whether the plan requires a referral for service, and whether their plan will cover the scheduled procedure, and at what percentage. The devil is in the details and, often, merits thoughtful, well-trained billing and administrative professionals who can add additional support for your practice. Furthermore, you must take a more in-depth look into eligibility verification both before treatment and after a claim has been denied. If your processes have gaps, money is being unnecessarily lost.
Strategy, at a glance
Before a patient arrives at the office, you should already know:
- The patient’s insurance policy
- Policy coverage for the service or treatment the patient intends to receive
- How much insurance is responsible for
- How much the patient is responsible for
- Any requirements needed by the payer to get the claim approved and paid
It’s ultimately the patient’s responsibility to understand the parameters of their own policy. The patient is responsible for any expenses incurred – even if those expenses result from a denied claim. The reality is that too many practices often verify coverage and file claims on the patient’s behalf. This ownership on your end can result in unpaid claims and lost revenue, so make sure to clearly communicate to your patient that they are responsible for the cost of treatment.
Identifying the Payer
Beyond plan coverage, specialist providers should be aware of payer guidelines. For example, an insurance provider may not always cover a skin lesion’s removal if the treatment does not fall under a specific diagnosis code, or if the visit falls under a particular scope of care. In this example, the physician would need to know in advance that the insurance provider will not authorize payment for the service and should have a strategy in place for identifying the patient as the payer. If a practice frequently deals with out-of-network plans, this strategy is even more crucial. Administrators need to do everything in their power to collect from the right payer, whether that be an insurance provider or the patient themself, especially if you want to make out-of-network services worth the cost.
Elevate your Pre-approval Process
One simple step to make sure you’re collecting every collectible dollar is to get pre-approval for every payer who requires one. Enhancing your eligibility processes means doing the work ahead of time to prevent claims denials.
Obtaining pre-approval is essential to driving revenue. More often than not, when a payer denies a claim because of a lack of pre-approval, the claim won’t be paid at all. If the patient is billed for the amount due, it’s unlikely that they will make the full remittance. Pre-approval should be considered mission-critical. If you don’t have a pre-approval process in place, one that is being meticulously followed by your team, you’re at risk of leaving far too much money on the table. If you’re wondering how to speed up prior authorization, expert support is available that can aid your team and give you peace of mind.
Be Aware of Deductibles and Benefit Details
Hopefully, you’re already making it a priority to get up close and personal with your patients’ insurance providers as well as working on getting approvals where required. While you’re at it, make it a point to check deductibles and benefit details as well.
Be sure to check:
- Whether the deductible has been met
- Specific coverage rules
- Whether the procedure is covered
- How the plan handles procedures
Verifying this information ahead of time helps set a standard with your patients so they know what to expect from your office. It may seem tedious, but your due diligence to ensure eligibility for every procedure, no matter the value, will result in higher reimbursement rates across the board.
Advanced Eligibility Checklists
As you work to develop enhanced eligibility tactics within your practice, ask yourself the following questions each time you determine a patient’s eligibility:
- Does this patient need prior authorization?
- Has the necessary approval been acquired?
- Has the patient reached the deductible limit?
- Do you know the particular CPT codes and modifiers?
- Have you reviewed specific or specialty coverage rules?
To assess the health of your prior authorization process, ask yourself the following questions:
- Do you place a higher value on surgical reimbursement as opposed to clinical?
- Are you keeping tabs on your key performance indicators (KPIs)?
- Are you analyzing your KPI reports?
As you review your eligibility strategy and processes, consider whether you have enough trained staff to ensure that prior authorization becomes a core focus for your practice.
Committing to excellence in your eligibility tactics is sure to enhance the prior authorization procedures in your practice. Develop a growth mindset and a plan of action for eligibility procedures and ensure your front office staff understands the importance of their role in this endeavor. Doing so will make all the difference in your revenue collection efforts.