The number of reasons including drug interactions and need of medical necessity is a salient point to be considered during prior authorization.
The consequences for a practice will be huge as the requested service will be denied and the insurance company looking for an alternative procedure.
The filing of appeals reviewing the entire medical process is a tedious affair that takes a toll on a provider’s staff and financial outcome.
Evolution of medical science and drugs and its impact on step therapy is something every care management provider intends to see.
However, insurance companies have some mandates that they need to abide by in respect to the fail first requirement.
One of the pertinent areas of challenge for any provider today will be to comply with the step protocol set by payers and secure quick prior authorization.
Managing high levels of availability for the patients has to be paced with the recent trends and developments in the prices of the drugs.
The healthcare providers today are in an increased pressure situation with surging costs of medical prescriptions.
While there are disagreements between managed care providers and physicians over the step therapy, securing financial reimbursements with quality checks and balances will be the key!
Fail first requirements hurts the physicians, the patients! A modern provider has to ensure that they meet the fundamental needs of the existing claims adjudication process.
Challenges in first time Prior authorization requests are many.
The amount of time and money that gets wasted annually is still a great sign of worry for the healthcare industry.
The idea should be to employ a specialized team that seamlessly shares information knowing the present day practice management requirements.
The entire process right from contacting the patient’s insurer, verifying the eligibility, submission of the prior authorization form to getting the final approval has to be streamlined.
Reducing the time in getting prior approval is a key segment that every practice will need an expert advice.
The insurance companies are of the view that authorization and verification prevents the need of unnecessary medical procedures.
It also advocates the cost saving purpose for the consumers and giving them a formidable shield from the encounter with potentially dangerous drug encounters.
A modern practice will have to keep all these factors in balance with their prior authorization process with a team that knows payer guidelines better.
Ensuring quality denial management will surely depend on a transparent authorization job. Every year, we find an increase in the costs that a practice faces with prior authorization.
PA requests cost to the health plans are roughly estimated at $10 to $25 for each. It is an area that requires services that are cost effective and more professional.
A business partner that provides end to end revenue cycle management support is the key. Any practice will be in need of a competent billing office with a unique understanding of modern payer adjudication perquisites. In most cases, companies with an excellent blend of experience in working with TPA’s, payers and helping them in their adjudication work will be a big bonus.
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