An insurer is just about the only healthcare stakeholder that doesn't have reason to detest prior authorization since it's a strategy for managing medical costs.
The bottom line is that prior authorization is fundamental to physician compensation and quality patient care. Failure to secure it in a streamlined manner can ultimately cause workflow inefficiencies, frustrate patients and staff, and potentially take a bite out of revenues.
"When I started here, the only procedures requiring prior authorizations were surgeries," wrote Robin S. "Now medications, radiology and in-office procedures require prior authorization, or you do not get paid."
Clearly, then, it's not just revenue that's at risk for practices; it's also their ability to provide quality care – and as value-based care becomes more mainstream, the two become increasingly synonymous.
Granted, preferred provider organizations (PPOs) are more popular than HMOs. But even PPOs include aspects of managed care. These plans might not mandate referrals, but nearly all insurance plans require prior authorizations to be obtained for certain healthcare services.
Which brings us back to the question at hand: How can practices more effectively keep up with who needs a referral or authorization and for what services?
Prior authorization needs to be treated like referrals; that is, as a pre-appointment task. This was all but impossible until providers began implementing digital practice management tools.
In theory, PM software ensures the appropriate referrals or authorizations are obtained in a timely manner so that they can be attached to a claim prior to submission. This ideally happens before the patient encounter to avoid delays in prescribing medications or treatments. Patients whose prior authorization is checked off ahead of time don't have to wait as long for payers to provide the all-clear. The benefits here include:
Your PM solution should allow you to set payer requirements by insurance in regards to the need for referrals and authorizations. However, specialty practices are all too aware that this is not as cut and dry as "certain patients or certain services always require a referral or authorization." Some payers may require a referral for an office visit and an authorization for specific services like surgery. Other payers might not require a referral for office visits but will demand a referral for special services like physical therapy.
A best-in-class PM solution handles payer discrepancies in a few ways. First, the PM predicts services and treatments that will be rendered based on each visit type and the patient's insurance plan. Ideal PMs should notify staff at the time of appointment creation or when reviewing office calendars via highly-visible colors and pop-up notifications that referrals or authorizations are necessary for the services that are scheduled. This helps ensure that all referrals and prior authorizations are in hand by the time treatment is prescribed.
AllMeds all-new PM not only provides helpful the notifications described above, but also allows your staff to manage multiple referrals and authorizations on patient accounts and allows the user to easily identify available referrals and authorizations to attach to claims. In other words, if prior authorization and referrals already exist, AllMeds PM makes sure your staff knows about them, and, better yet, doesn’t make them go digging for them.
The result: Expedited care delivery, better patient satisfaction and improved revenue collections.
Contact us today to learn how AllMeds all-new PM can reduce your prior authorization troubles and help your practice in many other ways, too.
Contact AllMeds today to learn how AllMeds all-new PM can reduce your prior authorization troubles and help your practice in many other ways, too.