Prior-Authorization Current Trends and Best Practices

There are several parts to seeing a patient and receiving payment for professional services. Eligibility ensures that the patient’s insurance coverage is active on the date of service that the services will be rendered and that their plan covers the services planned. There are different methods of receiving eligibility information and we are going to discuss these. Once eligibility is verified, certain procedures require the provider to contact the insurance company to receive prior authorization.

Unfortunately, every insurance company has different requirements, making it difficult to manage. It is important that offices keep track of the current policies for the insurance companies they work with the most, and ensure these authorizations are performed prior to the service being performed. Medical necessity is normally reported by the ICD-10-CM codes. These codes justify why a procedure or service is performed based on the patient’s condition. The insurance companies may have policies that define the services they consider medically necessary based on the diagnosis. If the information on the claim does not meet their guidelines, the claim will be denied.

• Understand prior authorization and how it is different from eligibility and medical necessity
• Know what will be needed to obtain prior-authorization
• Recognize the policy variations between insurance carriers
• Learn the new prior-authorization requirements of Medicare.

• The information that should be obtained when verifying eligibility
• Methods available to obtain eligibility efficiently
• Information needed for services to be approved for prior authorization.
• Tips for dealing with changes that occur in the procedures after they occur
• Major insurance company information to understand specific prior authorization processes
• Finding medical necessity policies for the major insurance companies
• Writing an appeal when a claim is denied improperly.

In order for providers to receive reimbursement for professional services the insurance company must receive a clean claim. Part of creating a clean claim is verifying the patient has coverage, obtaining prior authorization if necessary, and ensuring that the patient’s condition meets the medical necessity described by the insurance. Attendees will gain knowledge about these issues and understand the processes necessary to streamline this into the workflow for efficiency.

• Billers
• Coders
• Administrators
• Collector
• Supervisors
• Claims adjusters
• Reimbursement Specialist
• Providers-Physicians, therapists, Non-Physician Providers
• Surgery Schedulers
• Prior authorization staff.