An introduction to Prior Authorizations Services
If you are already in the healthcare business in the US, you probably needn’t be told about what prior authorization services are. You have probably spent hours cursing the process for keeping your staff busy with its many unrelenting and fastidious requirements, but without respite, because your revenue depended on it.
Essentially a system used by insurance payors for formally approving a prospective medication, medical device or treatment for coverage, prior authorization (also called pre-certification or prior auth, or simply PA) is critical for getting many claims for reimbursement passed. Ignore it, and you could have your patients forced to pay the entire cost out of their own pockets.
Problems commonly faced with prior auth requests
The main one is compliance. In other words, it’s about adhering to every little detail or norm as demanded by different payors. There is hardly a common format or set of guidelines, and requirements vary with every other Health Plan.
To add to it, there are other related issues like missing patient information, using the wrong codes, inadequate supporting documentation, absence of a statement of necessity from the prescribing physician and so on. A slip in any one of these leads to delays in getting the prior auth request approved, and in some cases, to outright rejection.
Last but not the least, prior authorization services are extremely time-consuming, involving long waiting periods for the process to get completed, and then waiting further for the insurance company to finally reach a decision.
How does outsourcing help?
Most healthcare providers, especially the busier ones, find that maintaining an in-house staff to handle all their prior auth tasks puts a severe strain on operational expenses, time and overall profitability. Productivity also suffers if there is an incompetent, or unknowledgeable, team of medical billers involved.
This is probably the biggest reason why so many healthcare practices across the US continue to outsource their prior authorization services to professional, dedicated and specialized service providers. According to one source, outsourcing can lead to a 30% to 40% reduction in operational costs. It also saves you from having to learn about the ever-changing norms of different payors or maintaining compliance and other such issues.
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