Prior Authorization Rules: Insights on a Challenging Process

Purportedly healthcare payors require prior authorizations for certain procedures to ensure that the patient is receiving a safe treatment that is medically necessary and appropriate. Yet according to a 2021 survey conducted by AMA, 93% of physicians report having experienced delays in access to necessary care and 83% of physicians find some patients abandoning their recommended treatment due to prior authorization delays or denials.  The authorization process has increasingly become an administrative burden to implement, especially as payors continue to make changes to their policies.  

While many billing companies recommend “embracing technology” by utilizing online payor portals for prior authorizations to save time, that process is not suitable for out-of-network providers.  Instead, for the OON surgeon, success is predicated on connecting directly with the payor representative.  While this is more time-consuming, it is a critical step to obtaining supporting authorization documentation should the billed charges be denied or a claim is under-reimbursed.

Since every payor has different requirements and there are variations depending on the type of service performed it is important to stay up to date on each payors’ requirements, a task that can be challenging and time-consuming for most practices.  Virtually all health plans are subject to either ERISA prior authorization rules or State laws that require insurance companies to establish and follow reasonable claims procedures including any prerequisite for obtaining a benefit such as preauthorization procedures.  This information and the applicable time frames are found in the patient’s health benefit summary plan description issued by the insurance company. Understanding a patient’s plan requirements is an important part of the preauthorization process for the out-of-network provider.

At CH Revenue Management Solutions, we recognize that a successful prior authorization process is contingent on having a designated prior authorization specialist(s) handling the work.  Our specialists have a keen understanding of the nuances of each payor and the impact these requirements can have on the preauthorization process and subsequent reimbursements if not properly managed.  We make it a priority to become familiar with our clients’ practice, including the common procedures performed, and to keep apprised of the changes in payor requirements.  Our team is highly skilled in devising authorization strategies, including GAP exceptions and LOAs, on a case-by-case basis to set claims up for maximum payment.  In the event authorization is denied we continue to pursue approval through peer-to-peer reviews and internal and external appeals. 

Due to authorizations being time sensitive, our specialists follow a methodical process that requires continuous follow up with the payor for status – it is important not to rely on the payor to communicate an approved authorization in a timely manner even when it is required by applicable law.  We consistently request an estimated turnaround time to process the authorization and when possible, ask for the prior authorization to cover a date range instead of a specific scheduled date to prevent having to resubmit an authorization in the event a patient needs to reschedule a procedure.

CH Revenue Management Solutions is a single source solution for out-of-network providers that has the expertise and resources necessary to handle the onerous preservice authorization process, appeals and Federal No Surprises Act and State surprise bill claims to maximize payments.   Our company leverages, among other factors, all health plan documents, regulations, payor payment data and requirements together with the preservice authorization information from our out-of-network medical billing team to set our client claims up in a way that offers the most pathways for pursuing a fair and reasonable payment for services performed, at every stage of the revenue cycle management (RCM) process. Our standard operating procedures include a concierge level of service for our clients with each claim processed with the same care and attention providers give to their patients.

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