Physicians are under increased stress to provide timely care. They issue prior authorizations (PA) for treatment without fully assessing the patient’s condition. To address this problem, several states have passed pre-auth reform laws that require physicians to obtain a full evaluation before issuing a PA. These laws are working to improve care while managing physician resources, and they can help practices ensure that they receive the appropriate medical treatment when necessary.
Challenges with Prior Authorization:
In its recent study, Kaiser Family Foundation looked at various medical services, treatments and prescriptions subject to prior authorization (PA) within Medicare Advantage plans. At 99%, durable medical equipment (DME) topped the list, with home health services following at 92%.
In such instances, an insufficient verification process could mean huge revenue loss. That’s why prior auth should be a priority for healthcare providers.
Prior Authorization (PA) is usually required if a patient needs a complex treatment or prescription. At times, it unnecessarily burdens doctors and patients as patient eligibility verification requirements are often redundant, inflexible, and time-consuming. This makes it difficult for physicians to provide the best possible care for their patients. For instance, a patient may be refused treatment because their doctor did not have enough information about their condition to determine if the treatment was appropriate. This can lead to serious health complications.
Ways to reduce the burden of PA on doctors and patients:
i) Policymakers should create more consistent standards across states so that everyone has access to the same level of care.
ii) Lawmakers should simplify and streamline PA requirements to make it easier for doctors to comply with them.
iii) Policymakers and insurance companies should develop initiatives aimed at reducing red tape in healthcare systems so that more treatments can be authorized quickly and without hassle from bureaucrats.
Streamlining Pre-Auth With Jindal HC:
After surveying providers, more than half said they don’t have enough time to complete PA. The process includes filing claims about specific Current Procedural Terminology (CPT) codes followed by the approval or denial after review by the payor.
That’s why it’s important to streamline the pre-auth process. It helps healthcare providers meet payer-specific requirements, remove manual administrative & coding errors, and save time and costs.
At Jindal Healthcare, we break this process into four components:
Requirements: Based on factors such as payer, plan, service type, and CPT/ HCPCS codes, our team assesses whether pre-auth is needed or not real-time.
Pre-screening: Leveraging data received through EHR analysis, our Revenue Cycle Management (RCM) experts check the submission for errors, information gaps and medical necessity.
Submission: We submit the pre-auth claims for approval via e-fax, payer portal or an EDI 278 transaction to speed up.
Monitoring: Keeping a track of the request’s status is simplified when the process is streamlined. We maintain a lead of 20 days to get approvals for the medical services or prescriptions and you always receive reports of approvals or denials as they happen. Although, our claims rates have been above 98%.
Physicians have become increasingly burdened by getting approvals for specific treatments and medications, which has led to poor patient outcomes and sometimes reduced claim submissions and increased denials. If one wishes to reverse this trend and improve patient access, one needs to streamline the prior authorization process. Contrary to popular belief, healthcare providers can deliver quality of care without worrying about the approvals cycle or finances. Learn more