Authorization
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Authorization
Intelligent automation to compare authorized codes to charges before claim submission.
Automation that requests authorization by uploading medical records, CPT/ICD10 codes, treatment plan, orders and completes auth request questions via portal or auth e-fax request forms. IT DOESN’T STOP THERE. The automation will continue to check status and brings the approved authorization back into your system so that it will drop on the claim.
Because the automation is customized, you are not limited to payers that offer auth through EDI exchanges. If a person can do it online or via fax, so can our customized automation.
How does prior authorization work?
The current prior authorization process typically resembles the following flow:
- First, a healthcare provider determines that a patient needs a specific procedure, test, medication or device.
- The onus is on the provider to then check a health plan’s policy rules or formulary to determine if a prior authorization is required for the prescribed course of treatment. If it is required, the provider will need to formally submit a prior authorization request form and sign it to attest that the information supporting the medical necessity claim is true and accurate.
- Because clinical and healthcare billing systems are rarely integrated, provider staff will often start by manually reviewing prior authorization rules for the specific insurance plan associated with the patient. The rules may often be found in paper documentation, PDFs, or payer web portals.
- These payer rules are not standardized and differ from health plan to health plan. It is not uncommon for the rules to even differ from plan to plan within a specific payer. These payer rules also change frequently, so a provider’s administrative staff may be referencing out of date rules.
- If the provider confirms that prior authorization is not required, it can submit the claim to the payer. This does not mean that the claim will necessarily be approved.
- However, if the provider confirms that prior authorization is required, it will need to track down more specifics pertaining to each CPT code that is applicable to the prescribed course of treatment. It will also need to obtain a number assigned by the payer that corresponds to the prior auth request and include it when the final claim is submitted. These steps are usually done manually, often through a cascade of phone calls, faxes and emails between payer and provider.
- The responsibility falls on the provider to continue to follow up with the insurance company until there is resolution of the prior authorization request — an approval, redirection, or denial. This part of the process is unstructured and often improvised, which often leads to significant wasted time and effort.
Why is prior authorization so complex?
The prior authorization process is often complicated by a combination of factors, including:
- Lots of required steps, each introducing the potential for delays and errors.
- Participation by both payers and providers, each of whom have different motivations, workflows, and infrastructure.
- Lack of standards, particularly when it comes to payer rules.
- Fluctuating payer rules which need to be constantly monitored and revised.
- Thousands of payers and health plans.
- Manual review of prior auth requests and medical charts by clinicians.
