All about ‘prior authorization’:
Prior authorization, which is also known as precertification or prior auth in short, is a key process used by healthcare service providers to verify insurance coverage. The process mainly determines if the particular product or treatment will be covered before prescribing it to the patient. Without this prior approval, your health insurance may not pay for your treatment, leaving you to foot the bill instead. The prior authorization process however has many different names including pre authorization, Prior Auth Services etc.
Why is prior authorization required?
Healthcare prior authorization, which is the process of obtaining approval for a particular medication or treatment before prescribing to the patient, is a necessary part of the revenue cycle management for a healthcare practice. It is mainly used:
● To keep healthcare costs in check
● To help in curbing overprescribing
● To ensure the medication or treatment isn’t being duplicated
● To ensure that the medication or the treatment prescribed is medically necessary
● To make sure that the medication is actually beneficial to the patient
Now the question is, what types of medical treatments and medications need prior authorization?
Starting from drugs frequently used for cosmetic purposes to medication that may be unsafe when combined with other medication – they all need prior authorization approval. It does not end here. Medical treatments that have a lower-cost alternative and effective treatment available also need prior authorization. And medical treatments and medications that are often misused or abused fall under prior authorization approval.
However, even though the process of pre authorization is to ensure the best solution that can help the patient, it is a controversial topic. This is because prior authorization services often lead to treatment delays. Being an obstacle to patient care, pre authorization services often act as a hindrance to the patient’s progress, placing administrative burdens on physicians and staff. The same applies to re-authorization which is a recurrent necessity for many services, especially in the DME/HME and Physical Therapy space.
Challenges of the prior authorization services:
The main three challenges that most providers face in the pre authorization process start with:
Being unaware of prior authorization regulations – With the evolvement of healthcare technology and medical science, the number of insurance plans is increasing with each day, each with its own forms, policies and regulations. This makes it difficult for providers to keep up as the requirements keep changing; resulting in failure to authorization approval. A denial in PA is lost revenue, decline in patient satisfaction and delay in patient care.
Working with outdated information – Pre authorization can often be denied due to outdated or incorrect information. When the doctor or pharmacist submits incomplete authorization data, it leads to prior authorization errors. According to research, 70% of payers stated their authorization request being denied due to inconsistent guidelines.
Spending too much and too long on prior authorization – Prior authorization services can be frustrating and time consuming. In fact, survey has shown that 86 % of physicians experience high and extremely high prior authorization administrative burden due to the pre authorization process or its services. Physicians in fact have long expressed their dissatisfaction with the time they and their staff have to spend on getting their prior auth done.
◐ Also, according to a survey by AMA – 90% of physicians reported that prior authorization processes caused delay in patient access to necessary care.
◐ 44% of doctors say PA requests “often or always” hold up care.
◐ 26% of physicians stated waiting for three business days or more on average to receive PA decisions from health plans.
While the average time spent on the overall authorization process can end up taking up 45 minutes for each pre authorization submission, it not only adds up the administrative cost for practices but also interrupts your patient care.
This is why you need Sunknowledge.
The Sunknowledge approach:
Taking care of the prior authorization responsibility – starting from authorization initiation, approval and follow-up, Sunknowledge experts helps in closing all the prior authorization gaps faster and effectively.
Extending unparalleled support in prior authorization services for more than 15 + years, we are your one-stop destination with 99.9 % accuracy and the highest productivity metrics. Following 100% HIPAA compliance guidelines, we further help in reducing your operational cost by 80% in a secure and efficient manner.
The Sunknowledge edge in prior authorization:
● 100% PA submissions on the same day itself
● 90% approval of your PA requests
● Increase of current rate of completed requests by 1.5 – 2X
● Turnaround time less than 48 hours max.
● Real-time audits and custom reporting according to your protocol
Our success story:
Being the only pre authorization solution to work successfully with one of our clients for obtaining prior authorization for a quasi medical product like the Botox, primarily needed for cosmetic purposes is in fact something we are proud of.
So what are you waiting for? Reducing your administrative burden for pre authorization process is just a call away. Let our experts optimize improve your authorization process and help you grow your revenue.
What is the difference between pre authorization and prior authorization?
Known as precertification, prior approval or prior authorization, eventually both the terms means the same thing. Essentially your health plan will require prior authorization for selected services before receiving them, not applicable in an emergency.
Why do denials happen in prior authorization?
There are multiple reasons for it! An insurance company can deny requests with the physician not performing the steps according to prescribed protocols. Also, filing the paperwork wrongly with missing information such as incorrect service code and date of birth and not having a consistent contact with the payer office are some of the reasons.
How to check the status of prior authorization?
The status of your prior authorization is checked by calling the Customer care number which can be found on the back of your member identity card.
Is there an appeal for prior authorization denial?
The initial level appeal involves the physician and the patient contacting the insurance to reconsider the denial. Also, the doctor may contact the insurance plan’s medical reviewer as part of peer to peer review for challenging the decision made earlier.
Can I improve my collections with accurate prior authorization?
Yes, accurate prior authorization upfront eliminates a lot of back end work with denials and hassles in collecting your payments on time. Going back and forth is negated with a transparent approach in practice management that accelerates collections in the long run.
What makes Sunknowledge unique?
Knowing the in and out of the industry, we know how to get your prior authorization approved. In fact, we have a 90% approval rate with our mastery in prior authorization services as we offer exceptional support at next door rates.
Presently, Sunknowledge has no transaction charges, training or installation costs, provides dedicated support. Let our experts share our references with you to demonstrate our quality. Our team will be glad to give you a complete preview on what difference we bring in with our comprehensive prior authorization action plan.