Prior Authorization Services in Texas can be painstakingly frustrating. As a doctor your first and foremost responsibility is to treat your patient with utmost care and attention. But the mountain of paperwork that comes with medical billing services in Texas can make it extremely difficult for you to manage your time. Lack of prior authorization always leads to an increase in denials, which can have a negative impact on your revenue. Healthcare system is a fast evolving one, it is incredibly important to keep up with its pace.
Prior Authorization ensures if the patient’s insurance covers a service, procedure or medication before its administered. Patient experience is a key aspect here as if this process is not conducted smoothly then it can absolutely hinder their experience altogether.
Many payers or insurance providers require prior authorization to be conducted before they agree to cover any charges. It confirms that the medical necessity that has been proposed from the service aligns with the provider’s guidelines. It is necessary for everyone included in the process as it streamlines patient care, it helps the insurance providers in cost saving and provides a sense of financial security for healthcare providers.
Challenges with Prior Authorization
Delay with Patient Care
There are times when it takes a long amount of time to authorize, which ultimately leads to delay in patient care. If the process is not outsourced, then it eats away a doctor's time. The time that is supposed to be utilized for patient care gets wasted in this process. This can be particularly problematic for patients who require urgent care and can result in serious adverse health impacts. The process in itself is intricate, because of multiple steps and requirements.
Another reason behind it could be poor communication. It is very important for the provider, patients and the healthcare plans to be in communication and collaborate to eradicate the delays from the process. One unintended side effect of delay in patient care can lead to patients choosing the emergency room to avoid the delays. But what they don’t realize is that it leads to a huge bill which won't be covered by their health plans.
Increase in Administrative Burden
The administrative effort required for this process is massive, from tracking to completion. This could lead to a diversion of resources from patient care to administration and by the end it won’t be just the patient suffering due to this. This increase in administrative burden can lead to increased healthcare spending, some sources mention that it can even go up to billions of dollars annually.
Prior authorization leads to such a massive workload. And later it results in a negative impact on patient care and an unavoidable burnout. A lot of insurers require unnecessary prior authorization for treatments and procedures that are well established and come under standardized healthcare.
Denials and Appeals
There are a few common reasons for insurance providers to deny your claims. Reasons like improper coding, medically inappropriate services, non-coverage by the healthcare plan, etc. When a healthcare provider is denied a claim, the insurance provider is required to state the exact reason for which the claim is being denied. This is done to give a big enough
timeframe to the physician to discuss this with the reviewer. Although this only applies to the denials caused by lack of medical necessity. The claims which are denied because of
not being covered in the benefits are mostly cosmetic procedures, and they do not come under this category.
Whatever the reason behind the claim being denied, an appeal can be put through to demand to reverse an adverse decision. In most of the cases, a patient has 180 days to file an appeal. Insurance providers are required to inform their members about the timeframe for appeals beforehand. However, there are several patients who are not aware of their rights when it comes to denials and appeals.
Lack of Data Consistency
There is a lot of inconsistencies in data which can be found in every nook and corner of this process. From how the payers are using the codes to how the status update is being communicated, inconsistent data can be found anywhere. This creates barriers to automation and efficiency, because if the data is lacking the required information, then it is nearly impossible to automate the process as it would lead to incorrect results every single time.
The lack of standardization results in confusion and errors. This makes it even more difficult for providers to submit the prior authorization requests on time. It also depends on the level of service of care being provided as everything has a different set of requirements. It also leads to lack of transparency as these errors caused by the absence of standardization make it easier for providers to deny claims and blame it on the health care professionals.
Ever Changing Payer Rules
One of the most prominent challenges in prior authorization is the ever-changing payer rules. These rules are frequently updated throughout the year causing chaos all around. Every health plan is different in nature and patients opt for a variety health plans according to their needs which results in every requirement being completely different as well.
This creates an inconsistency in requirements amongst the payers, and vague or opaque requirements. Shifting these rules again and again increases the complexity level for health systems, and results in them not being able to keep up with what they must get prior authorization for and what doesn’t require prior authorization.
How Can you Overcome these Challenges
Better Communication with the Payers
It is better to clarify every detail necessary for this process with the insurance payers. This would help you avoid any potential issues before submitting the request for prior authorization. It is also very important to stay up to date with every payer requirement or guideline that has been presented to you like documentation needs etc. Through all of this, open communication is a must, if the concerns are addressed as soon as they arise then the approval rate is bound to increase.
Accurate Documentation
Documentation plays a crucial role in each and every stage of this process. Thorough documentation ensures that no mistakes are made in the patient records. Accurate coding is a part of this process, reporting the adequate medical codes for the specific medical necessity is what makes or breaks your case. Professional prior authorization service is the best option available out there to take care of this task with precision and efficiency.
Leveraging Technology
Electronic health record systems can be integrated in prior authorization to ensure that the patient information is accurate and can be used further down the process. Automated alerts can be used for sending timely reminders to the patients or following up with them for pending authorization requests. Using AI and automation can streamline the workflow entirely, making it a smooth experience for everyone involved.
Focus on Core Competencies
Healthcare professionals prioritize the well-being of their patients before everything else, but extensive processes like prior authorization make it difficult for them to dedicate all their time and effort towards the patients. So, instead of making it a problematic experience for everyone, outsourcing to prior authorization services can be considered as an efficient alternative. While the healthcare professionals focus on providing the best care possible to their patients, we at Eminence RCM can take care of prior authorization requests for them.
Staying Informed and Organized
Above all, staying informed and organized is an absolute must. You have to keep up with industry standards to maintain a good reputation for you and your service. In order to do that, having a dedicated team is extremely important. The more efficiently you delegate the work amongst your team of skilled professionals, the better the results are bound to be.
A team working extensively behind this task can improve the workflow in more than one way. From creating a master list of medication required for prior authorization to following up on pending request, everything is simplified when a skilled profession is responsible for the task.
Conclusion
In conclusion, prior authorization does not have to be as frustrating as it seems as there are ways for a healthcare professional to work around it. Outsourcing these tasks to a prior authorization service like Eminence RCM can help the doctors focus on their core competencies without having to delegate a fraction of their time everywhere. Navigating prior authorization on your own can be complex and even a little scary, but it does not have to be any of those.
With a massive amount of experience and a completely skilled team of professionals by our side, we can make sure that there are no errors and reduce the claim denial rate by a lot. Prior authorizations are fundamental to the healthcare system and leave no space for any mistakes on anyone’s part. Looking to minimize your administrative burden and not diminish the quality of your work in the process?
Partner with us at Eminence RCM and see the difference for yourself.
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