How to Overcome Insurance Denials in Prior Authorization

Physicians attend to patients’ needs throughout the day. After treating all patients, when they finally sit down to relax, they face a huge task to fight with payers regarding reimbursements. Revenue cycle management (RCM) in the US healthcare setting presents significant challenges for which most physicians aren’t ready. They have all the efficiencies to address patients’ needs. However, preparing clean claims usually isn’t their cup of tea.

As a result, they struggle to keep their revenue cycle shorter, and among the other processes in RCM, prior authorization (PA) presents the most complexities. Here, we first need to understand why securing prior authorization is so complex!

Why Prior Authorization Faces Frequent Denials

Providers need to apply for prior authorization to the patient’s insurance payers before initiating treatment or offering medication and medical devices. To secure payer approvals swiftly and seamlessly, providers need to properly justify the treatment necessity. They must assign proper medical codes that exactly describe the prescribed treatments and medication. On top of that, providers must attach all-inclusive documents that establish every detail mentioned in the PA request.

Providers, while managing both patient care and billing intricacies, often commit silly mistakes in PA requests. That leads to prior authorization denials. The primary reasons for PA denials are as follows –

Incomplete or Inaccurate Documentation

Payers go through every piece of documentation to ensure they have the complete picture of prescribed treatment plans. If a treatment is planned after seeing the imaging test results, providers need to furnish the test report, physician note, and other details that establish the authenticity of the treatment plan.

Failure to Meet Payer-Specific Criteria

Insurance payers in the US have customized policies for prior authorization approvals. Moreover, the policies change per government (Federal and state) payers and commercial insurers. Providers dealing with multiple tasks simultaneously often fail to stay up-to-date on regulations and payer policies. As a result, they face PA denials.

Insufficient or Missing Clinical Information

Clinical information includes all documents related to the patient’s treatment plan. That includes their medical history, physician’s notes, test reports, and all other relevant documents. If payers fail to find even a tiny detail, they will reject the PA request immediately.

Erroneous Medical Coding

Medical coding is significantly complex by itself. It includes a notably vast range of CPT, ICD-10, HCPCS codes, and modifiers that accurately describe the disease, treatment process, and medical supplies. Most small and medium-scale healthcare providers lack the budget to employ a full-time certified coding expert. As they result, they commit mistakes in medical codes that lead to PA denials.

Related Reading: Why You Need Professional Help Managin­g Your Prior Authorization Services

Wrong Patient Information

In many cases, payers deny PA requests due to wrong patient information. When patients initially visit the healthcare facility, the front desk staff need to capture their identity and insurance-related details accurately. When front desk staff tackle multiple responsibilities (Like answering calls, providing support, scheduling appointments, and managing other administrative workload), they often commit typos. That led the PA request to the denial list.

Lack of Medical Necessity

Establishing proper medical necessity is a top priority for PA success. Insurers sincerely follow all details and documents to ensure the treatment plan is necessary for the patient’s recovery. And so any expensive alternative treatment that is not in the health plan can be easily eliminated.

The above factors eventually become a pain point for healthcare providers, and they feel the urge to employ dedicated resources. For erroneous PA practices, providers not only face denials, but patients also suffer. Often, they face delays in getting medical services, and many of them even abandon treatments. Furthermore, patients’ condition often worsens while waiting for treatments.

Tips for Prior Authorization Success

From the above discussions, we can recognize the pain points related to prior authorization. It is crucial to turn rejections into success. Here are the top-notch suggestions to eradicate PA denials.

Review the Denial Letter Thoroughly

Payers provide the exact reasons for PA denials. Often, denials are due to administrative mistakes. It may be due to incorrect coding or missing documentation. Healthcare staff need to go through the denial letter received from payers. It will help them identify particular errors. If they fail to recognize the denial reasons by themselves, they must contact the insurers for clearer explanations. Understanding denial reasons thoroughly will enable providers to appeal with proper rectification.

Ensure Proper Documentation and Medical Necessity

As mentioned above, one of the most frequent causes of prior authorization denials is a lack of proper documentation. Missing documents will fail to establish the medical necessity of the prescribed treatment. Here, providers need to furnish the PA request with detailed medical records, evidence-based guidelines, and other related details.

Appeal the Denial: Steps to Take

After receiving a PA denial, providers have the option to appeal with thorough rectification. It is a pretty sensitive process where providers need to furnish evidence to challenge payer decisions. Here is how they can appeal effectively:

Understand the errors in claims to address exactly those. If payers think the PA request lacks medical necessity, providers must provide additional documents. They may provide additional diagnostic test results, specialist consultations, or updated patient records, as required by payers.

In addition to that, providers must follow the particular insurer’s appeal process. Every insurance company has a formal appeals process. Here, providers must go through the instructions from payers for a successful appeal process. Providers must ensure that they follow every payer rule accurately.

Most PA requests are denied by payers due to a lack of medical necessity. Hence, prior authorization services must ensure they clearly explain the reasons behind the prescribed treatment plan. They must justify how the treatment, medication, or medical devices will help the patient in full recovery.

Follow Up Consistently

After submitting an appeal, providers must follow up with payers regarding the status of the claim. Insurance companies are often overwhelmed with claims. Hence, they often may delay or even forget about a request. Providers must consistently follow up with payers, so they don’t hinder in approving. However, the follow-up should be friendly and polite. In addition to that, it’s equally important to maintain a professional and respectful tone. Providers must also note down every detail of their communication for future reference.

Related Reading: Simplifying Prior Authorization in Virginia: Avoid Errors and Save Costs

Partner with an Expert Prior Authorization Company

Medical billing experts are invaluable when it comes to navigating the complex world of insurance denials. Professional prior authorization experts are well-versed in the intricacies of coding, insurance policies, and the appeals process. These third-party PA companies usually have dedicated certified coders. Hence, they can catch even minor coding errors and rectify them without delay.

In addition to that, these third-party medical billing experts know all the requirements for a successful appeal. They have good communication with payers. It enables them to follow up with them and bring quick resolutions. Also, these PA professionals can monitor multiple claims simultaneously. It ensures their scalability and proves that they can address any increased demand.

How SunKnowledge Streamlines Prior Authorization

SunKnowledge Inc. has an established reputation in managing end-to-end revenue cycle management for more than 17 years. We have dedicated experts for each step of RCM, including prior authorization. With our support, providers not only secure pre-authorizations but also can simplify their entire billing process. We ensure the following to help providers streamline their RCM process.

• We ensure an over 97% first-pass acceptance rate in PA and claims
• We ensure optimum accuracy in prior authorization requests
• Our most affordable services are available for only $7 per hour
• Providers can reduce about 80% of their office expenses with our support

Hence, if you are searching for expert support to secure every PA request you submit, contact us without delay. Fill out the “Quick connect” form, hovering on the right side of your screen, and our experts will contact you with a customized solution. Together, we can make PA from a pain point to seamless success.