Prior authorization requirements for cardiology procedures have been increasing over the years, resulting in serious implications for patients, cardiologists, and healthcare providers. For patients, negative outcomes of increasing precertification requirements include delayed care, increased out-of-pocket expenses and deterioration of health, whereas for healthcare organizations, increase in PA requirements may result in lower reimbursements, longer payment cycles, loss of revenue, and negative patient experience. These complications are adding to the existing economical, operational, and inflationary challenges that healthcare organizations are trying to overcome.

It is of paramount importance to understand the common factors behind denial of PA requests and how professional RCM services can fill the gaps to reduce the utilization management (UM) burden.

5 Studies Highlighting Serious Problems with Prior Authorization (Cardiology Procedures)

  • A study published in the American Heart Association’s journal, Circulation, titled, ‘Cardiovascular Quality and Outcomes’ found that “precertification requirements have increased by 30% for cardiac procedures between 2014 and 2018, with the average time to get approval growing by 10% during the same period”.
  • A survey titled, ‘The Physician and Administrator-Reported Cost of Drug Utilization Management to Physician Practices: A Cross-Sectional Survey’, by the journal, PharmacoEconomics, found that “an average physician practice spends $853 every year on pre-approval related tasks”. The survey also highlighted that “90% of physicians reported that prior auth delays access to care”.
  • Another study published in Health Affairs reported that “physicians spend 16.4 hours every week on average on prior auth-related tasks including form fill-ups, request submissions, and denial management”.

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Most Common Cardiology Procedures with Low Prior Authorization Approval Rates

According to a study published in the Journal of the American College of Cardiology, the most common cardiology procedures with low prior authorization approval rates are:

  • Transcatheter aortic valve replacement (TAVR)
  • Percutaneous coronary intervention (PCI)
  • Implantable cardioverter defibrillator (ICD)
  • Heart transplantation
  • Heart valve surgery
  • Carotid artery stenting
  • Coronary artery bypass graft (CABG)
  • Electrophysiology (EP) procedures

Factors Responsible for Denial of Prior Authorization Requests for Cardiology Procedures

The pressure of increasing prior auth requirements is making the current economic and operational challenges worse for healthcare organizations. To ease these pressures and effectively deal with the problem of prior-authorization denial for cardiology procedures, it is crucial to understand the most common factors that insurers cite to deny approval.

  • Lack of medical necessity.
  • Experimental or investigational nature of the procedure.
  • Patient’s conditions don’t meet criteria for the procedure.
  • Patient’s health plan does not cover the procedure.
  • Incorrect submission of prior auth requests.

How Cardiology-specific Prior Authorization Services Help Overcome These Challenges

Due to the nature of their work, reputed healthcare RCM companies have to follow industry best practices. From leveraging automation tools to hiring certified cardiology prior authorization specialists, these companies leave no stone unturned in ensuring optimization of prior auth operations for their clients.

By strictly following standard operating procedures and industry best practices, revenue cycle management companies enable healthcare organizations to overcome challenges posed by increasing prior auth requirements by offering the following benefits:

  • Reduction in precertification waiting time.
  • Reduction in delays to care.
  • Significantly lower administrative burden.
  • Lower operational & labor cost.
  • Higher net income.
  • Fewer denials.
  • Shorter payment cycle.

Sunknowledge and Cardiology Prior Authorization Services

Selecting the right cardiology prior authorization services partner is as important as the decision to outsource prior auth functions. If not done properly, outsourcing operations can do more damage than good.

With an impressive track record of helping cardiology and cardiovascular practices of all sizes across the US, Sunknowledge is your one-stop destination for full support in prior authorization, along with seamless re-authorization, retro authorization+ and dedicated doctor’s office follow-ups.

+Even though we extend full assistance in retro authorization, it is not a guaranteed service as the outcome is extremely Payer-specific and subject to the Payer’s specific guidelines in this regard.

Our streamlined processes, quick turnaround time, diligent follow-ups and deep familiarity with prior auth requirements of various payers, make us your best choice for a competent partner to take the prior auth burden off your shoulders.

Only Sunknowledge assures you of:

  • Up to 80% cost reduction
  • 99.9% overall accuracy
  • 97% collection rate
  • FREE transition, training and on-boarding
  • FREE account managers
  • Full HIPAA compliant operations
  • No binding contracts
  • Hundreds of top-notch references

Contact us today to schedule a free consultation. Unleash the Sunknowledge excellence in your practice and be amazed!

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