Every insurance comprises a board of underwriters, and every plan has a list of medication which is covered under the plan. Not every drug prescribed by the provider falls under the formulary. Expensive drugs like Botox, Pradaxa, Xarelto etc. are not generally covered. For example, most insurance will not cover Vitamin D and you'll have to pay "out of pocket", which means, an authorization was required prior to dispensing it.
What Problems and Why Problems?
According to Ohio State Medical Association:
~ Prior Authorizations cost roughly $23- $31 billion nationally every year
~ It is reported that 69% physicians wait several days for a response to a PA request
~ Nearly 40% of PAs are abandoned due to complex procedures and policies, and nearly 70% of patients requiring PA do not end up receiving the original prescription their doctor prescribed for them
Additionally, 43% of physicians report that first-time PA requests are often reviewed by an insurer representative who has no medical experience. Therefore, it is too difficult to determine which tests, procedures and drugs need PAs. It is also said that in Ohio, insurers require 748 different paper PA forms for drugs.
On enquiring providers if their patients have received their medication, more than half of the providers had reported in the negative.
How To Curb The Problem?
A competent revenue cycle management company, preferably one with a 360O perspective on the process, modernizes and simplifies the method. And specialty pharmacies are among the long list of organizations that stand to benefit from this knowledge.
By virtue of a potent mix of expert skill, superior practice management systems and a multi-pronged approach to verification (phone calls, fax or online), dedicated third-party PA specialists are providing specialty pharmacies the right solutions to increase collections, reduce denials and cut down loss of revenue by a huge margin.
The growing complexity of government mandates, coupled with ever-changing payer guidelines, tend to make the situation challenging. However, this should be no reason for providers to lose money due to denied reimbursements or simply, due to a failure to check coverage, or secure the necessary authorization.
The need of the hour is to implement measures to make pre-authorization uncomplicated. And this can be easily achieved by employing dedicated experts to take care of this crucial component of the entire claim reimbursement process.
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