Health System Prior Authorization Services

Healthcare costs in the US are often so high that for many patients, out-of-pocket expenses beyond insurance coverage become a significant hardship. This is where the need to have efficient Health System Prior Authorization services arises. When providing treatment to a patient, you aim to ensure that the patient’s insurance company pays the maximum coverage amount as quickly as possible so that the patient doesn’t have to bear any out-of-pocket expense. The primary role of prior authorization in the healthcare system is to protect healthcare providers and their patients.

For healthcare providers, placing a strong emphasis on adhering to the payer’s guidelines regarding the facility where services are provided, treatment expenses, medication selection, and coverage status for complex and expensive procedures is crucial. However, there might be exceptions in certain emergency or critical situations. Neglecting to acquire prior authorization may lead to significant financial responsibilities for the patient and revenue loss for the provider.

You aim to earn your patients’ trust by providing them with the best care possible, which means selecting appropriate treatment plans aligned with their insurance coverage. It’s also essential for you to educate patients so that they can achieve maximum outcomes. Prior authorization must be obtained from the insurance company ahead of any anticipated diagnostics, medications, or procedures to ensure subsequent assurance that the patient will receive optimal coverage.

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Challenges Facing Health System Prior Authorization Services

It is widely acknowledged that streamlining operational tasks, particularly practice management, medical billing, and accounts receivable management, is imperative. Additionally, establishing a clear and transparent strategy for prior authorization services is essential for providers to thrive in intense competition.

Regrettably, many medium and small-sized healthcare providers face significant challenges and complexities in dealing with Prior Authorization requirements. Establishing a dedicated billing department for small or mid-sized healthcare providers comes with significant costs and administrative burdens. Many healthcare companies operate on a limited operational budget that hardly allows for developing a separate medical billing team comprising experienced professionals. Speaking of Health System Prior Authorization services, this is also true (even though Health Systems are generally perceived as large conglomerates and hence, better positioned to hire more people).

The bitter truth is, approaching prior authorization with inadequate resources – while it may appear to bring apparent savings – can actually be counter-productive. Here’s why.

Prior auths need a certain degree of tenacious pursuit. It also demands a dedicated and an organized approach. Initiating a request, following up with the Payer, clearly establishing the medical necessity and finally, obtaining the authorization – these are specialized tasks that require precision, punctuality, and deep knowledge about the pre-certification process as mandated by different insurance companies.

Another critical problem that many healthcare providers often face is being unfamiliar with the recent prior authorization guidelines. For instance, it may be unknown to some that the use of Health Plans’ internally developed clinical criteria to determine coverage has faced scrutiny. In California, for instance, plans are now prohibited from utilizing their own clinical criteria for medical necessity decisions. Instead, commercial insurers are mandated to adopt criteria aligned with generally accepted standards of care. These criteria are developed by a nonprofit association specific to the relevant clinical specialty.

Choosing a Health Systems Prior Authorization Outsourcing Partner

At Sunknowledge Services Inc., we bring our years of experience and hard-earned skills to streamline your end-to-end prior authorization services, ensuring you complete peace of mind. With close to two decades in the medical domain, we’ve been providing top-notch healthcare prior authorization services to Health Systems, large and small, across the 50 states.

Sunknowledge, one of the nation’s one of the best health system prior authorization vendors, is the preferred destination for thousands of healthcare practices for true billing excellence We consistently leverage robust and scalable technologies to minimize human error, reduce turnaround time, and significantly boost your revenue. With rates starting from $7/hour and operating on an FTE (Full-time Equivalent) model, we offer a high degree of flexibility, transparency and economy.

Prior Authorization for Health Systems needs a competent, knowledgeable and experienced partner. We are uniquely positioned to not only handle all PA tasks with utmost efficiency, but also scale up operations quickly with the growing needs of an active Health System.

Benefits of Health System Prior Authorization Outsourcing

In the realm of Prior Authorization, few can beat our experience, skills and precision. Here are some of the reasons why Health Systems across the US choose us for handling their Prior Auth tasks.

  • 100% request-initiation rate
  • STAT requests initiated within 15 mins. max.
  • Highly streamlined workflow
  • Substantial reduction in operational cost
  • Maximized reimbursement
  • Up to 80% reduction in current billing costs
  • Zero-cost transition
  • Free dedicated Account Manager
  • No binding contracts
  • Excellent references from reputed clients

Fact about Health System Prior Authorization Services: Excellence in Action

Most healthcare insurance companies have highly complex criteria for Botox approvals, making it very challenging to obtain them for an inexperienced PA professional. Our Prior Auth specialists have successfully managed to navigate the numerous loopholes and successfully obtain a Prior Auth approval for a quasi-medical product like Botox.

Experience true excellence in Health System Prior Authentication services by outsourcing to us!

Contact us today to schedule a no-obligation call.

Choose Sunknowledge as your Health System Prior Authorization Services partner to get more requests completed per day, and watch your collections soar. We guarantee the best productivity metrics for all your pre-billing requirements

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