Prior authorization in health care is a step during medical billing when a healthcare giver reaches out to the insurance provider for permit authorization treatment. This phase guarantees the service is medically necessary as well as rests within the scope of the patient’s policy to avoid denial of claim and incurring unforeseen expenses.
Similarly, one of the biggest challenges is submitting medical records and backing up the claim with needed information. Delays in authorization can affect a patient’s clinical treatment, so it is important to submit them promptly. MAVA Care automates as many routine tasks as appropriate in the authorization process to prevent human error. It is your go-to service for all billing needs. Let us help you today!
An Overview of Prior Authorization in Medical Billing
Some health insurance companies require prior authorization in medical billing before approving payment. Simply put, a doctor must receive authorization from the insurance company to allow a patient to undergo certain treatments. This enables the insurance companies to determine whether the treatment is essential.
This process could be used for:
- Medications, specifically specialty and high-tier medicines.
- Surgical operations that are high in cost and or multifaceted.
- Medical apparatus, for instance, wheelchairs and oxygen concentrators.
If a patient’s doctor considers it necessary, the insurance provider must receive the authorization request. The insurance provider assesses the request, and its decision will determine whether it will finance the treatment. Thus, dealing with a health insurance company is always timely; submitting an approval request as soon as possible is a good idea.
What Is Authorization in Medical Billing?
Authorization involves getting approval from an insurance company before performing particular medical services. In medical billing, it is also known as pre-authorization or prior authorization. In addition, without authorization, the insurance company can refuse the claim, leaving the patient with the bill. Doctors and hospitals wire the authorization request before providing treatment. The insurance company reviews the documentation and then determines coverage.
Likewise, each insurance company has unique policies, so it is always more than just important to inquire before providing the service. With proper authorization, fears regarding sudden expenses or treatment delays are non-imminent. Hence, proper authorization provides a solution to the problem of billing discrepancies.
How to Do Prior Authorization?
The healthcare professional checks the patient’s medical records to obtain their diagnosis code and treatment notes. Then, they bundle all the necessary paperwork and send it to the insurance company’s designated portal—this can also be done via fax or phone. There is no room for mistakes while sending the documentation because the patient may face unforeseen delays or a claim denial.
Additionally, depending on the payer, reviewing the claim takes anywhere from a few days to a few weeks. Once the claim is accepted, the patient can receive treatment from the doctor, but if the MAVA Care client is denied, they can file an appeal instead. Ultimately, no matter what the issue, MAVA Care is adept at managing prior authorization for medication because we know how to make the claim operational as quickly as possible. Contact us and feel at ease knowing that all the billing and paperwork are handled professionally.
Types of Authorization in Medical Billing
1-Prior Authorization
No medical services should be rendered without prior authorization in medical billing. The provider sends an authorization request directly to the insurer. This is the case with surgeries, costly diagnostics, and some prescription drugs. If not authorized, the insurance may refuse the payment. In such situations, the patient has to bear the entire burden of expenses, which can be considerable.
2-Retroactive Authorization
After completing a service, someone submits a request for retroactive authorization. This is common in emergencies where prior permission cannot be obtained. The provider submits the request to the insurer for payment of the service. The insurance company’s rules and regulations dictate the decision. If the decision is negative, the patient and sometimes the provider shoulder the cost.
3-Concurrent Authorization
You don’t need to get approval from an insurance company when you are under treatment for it to cover expenses. The insurance company assesses the patient’s status mid-way through treatment to determine if they need to spend more money. They use it in extended hospital stays and long-term rehabilitation. If these costs aren’t authorized, the patient might have to pay themselves.
4-Post-Service Authorization
Providers submit authorization requests after treatment is complete. A claim can default or be refused, meaning the patient ends up paying out of pocket. It’s best to apply for authorization beforehand rather than hope for the best. Those under treatment risk losing a lot of money financially.
Prior Authorization Process
1.Provider Initiation
A healthcare provider initiates the prior authorization requirement when they decide that there is a necessity for approval from an insurance company specifically concerning a treatment, procedure, or medication for a patient. Therefore, the provider assembles a supportive case by collating important information like medical history, physicians’ notes, laboratory investigations, as well as other pertinent tests done. The documentation thoroughness is important, as it justifies the case for medical necessity and necessity while increasing chances for approval.
2.Submission to Insurance
After the requisite documents are secured, the provider moves on with the submission of the prior authorization request to the relevant health insurance company. This submission has important patient information. For example, we provide patient demographics, diagnosis codes, procedure codes, and a brief rationale. You can submit the process electronically through a payer’s portal, via fax, or through a designated prior authorization platform.
3.Insurance Review
The insurance company starts the review process as soon as it receives the request and service documents. Additional supporting documentation, such as tests or physician notes, may be requested for clarifications, and sometimes, a tighter deadline is given to ensure there are no delays in processing.
4.Approval, Denial, or Request
Now that the review has been completed, the insurance company will select from four different outcomes, including some notable excerpts from the review. In such situations, the provider has the right to challenge the outcome. Therefore, the healthcare provider or facility must submit more supporting documentation before a final decision can be made.
5.Notice of the Action
Once the insurance company makes a decision, it updates the provider on the progress made. Upon approval, the provider shares the information with the patient and books any requisite treatment or procedure slots. If the decision is denied, the provider and the patient can agree on alternatives, such as an appeal. Effectively manage relationships with patients by providing proper communication lessons concerning their insurance coverage and the next steps.
Bottom Line
To sum up, when a patient’s medication or treatment documentation changes, an insurance company must confirm this through a process known as prior authorization in medical billing. Procedural coding within authorization requests can undoubtedly involve arduous and unnecessarily lengthy work. Any lag or rejection ripples cost implications throughout the practice.
At MAVA Care, we aim to supply expertly trained medical coders who strategically streamline healthcare billing processes to ensure compliance with the set policies. Visit MAVA Care to improve your reimbursement and income cycles with precise and organized coding.
FAQ’s
What are the steps that can be taken to facilitate prior medication authorizations?
Make use of existing hardware and submit documents accurately and completely, use electronic prior authorization (ePA) systems, and contact the insurance company regularly. Additionally, providing all clinical supporting documents to a dedicated prior authorization team can facilitate the authorization process.
What is the purpose of pre-approval?
Insurers have prerequisites for ascertaining medical requirements, avoiding excessive expenditures, and protecting patients from potential risks. They also control the prescription of expensive medicines, check adherence to therapy protocols, and stop the abuse of claims.
How much time does it usually take to get approval for a medication?
It can take a few hours to days to process approvals based on criteria like what provider is offering coverage and the medication itself. A person can process an urgent request for life-saving medications without any additional documentation within 24 hours.
Who is liable for preparing a pre-authorization?
Usually, the physician or the administrative professional looks after the request and authorization. The initiative can also be taken by pharmacists, especially when dealing with specific medicines.
