Skilled Nursing Facility Prior Authorization Services

Skilled nursing facilities are an important linchpin in Medicare covered managed care regime which includes post-acute, long-term care, rehabilitation, and geriatrics. However, convoluted regulations and strict prior approval requirements from Medicare Advantage (MA) payers are challenging for these important caregivers. As a leading service provider for skilled nursing facility prior authorizations (PA) we have helped care facilities across the US deal with the PA hurdle.

Before we delve into the advantages of our skilled nursing facility prior authorization services, here is a brief overview of the challenges that we solve.

Prior Authorization challenges facing Skilled Nursing Facilities

Healthcare prior authorization, in general, is a complex and evolving requirement as far as Medicare and private payer coverage determinations are concerned. A successful pre-certification and approval process is crucial for avoiding claim denials.

Over two decades of experience in the managed care authorization process has allowed us to pinpoint KPIs that frequently cause problems for long-term care facilities and nursing homes. Let us start with the strict pre-approval requirements.

SNF pre-authorization requirements:

1. Medical necessity: The services requested must be medically necessary and appropriate for the patient’s condition. This means that the services must be:

  • Ordered by a physician
  • Consistent with the patient’s diagnosis and treatment plan
  • Likely to improve the patient’s condition or prevent further decline

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2. Level of care: The patient must meet the level of care criteria for SNF This means that the patient must:

  • Need skilled nursing care daily
  • Be unable to safely care for themselves at home
  • Require at least one skilled therapy (e.g., physical therapy, occupational therapy, speech therapy)

In addition, some payers also require:

  • Documentation of attempts at home care.
  • Functional assessment to determine the patient’s level of need.
  • The patient’s prognosis (e.g., how long they are expected to stay in the SNF) before approving the admission.

Quick Pre-authorization for Skilled Nursing Facilities:

1. Start early: The pre-authorization process can take several weeks, so it is important to start early.

2. Documentation management: Documents such as physician’s orders, functional assessment, and prognosis need to be organized and made accessible.

  • Advanced documentation management systems despite their inherent cost simplify this process.

3. Accurate and timely submissions: Make sure the pre-authorization request is submitted accurately and completely to avoid delays.

  • Automated processes backed by skilled manpower allow fast and accurate filing of both general PA and stat requests.

4. Follow up: Constant follow-up with the insurance company helpdesk and representatives is crucial to getting approvals on time. Often, this can entail long telephone conversations and dealing with IVR systems – tasks that do not require the specialized skill-set of nurses and physician’s assistants.

  • When you outsource prior authorization services for SNF, you get access to a large pool of trained PA experts, freeing up in-house staff for essential duties and reducing costs.

5. Strong appeals process: Even after taking all these steps, payers may still deny a medically valid and necessary PA requests.

  • Some skilled nursing facility prior authorization services can help tackle denials due to excellent payer relations and a tenacious appeals process.

Getting paid involves an ongoing process of prior authorization for skilled nursing facilities. From antibiotics to blood anticoagulants for congestive heart failure (CHF), any additions to the daysheet may need to be pre-approved.

Although coverage depends on the specifics of a resident’s health plan, nursing homes often administer crucial medication without waiting for PA due to the length of the process. This translates to an unpaid charge that should have been covered by the payer following quick pre-approval.

With our expertise in obtaining hard to get prior authorizations even for niche, boutique, and dual-use medications, you no longer must resort to generic medication or fear time delays.

Our prior authorization process:Skilled Nursing Facility Prior Authorization

Outsource Prior Authorization Services for SNF

  • A 2023 study by the Commonwealth Fund found that SNFs outsourcing PA services experienced a 15% reduction in administrative costs compared to those managing it internally.
  • A 2022 study by the American Hospital Association (AHA) estimated that hospitals outsourcing PA tasks could achieve cost savings of up to 20%.

Yes, we all know the benefits of outsourcing SNF pre auth to specialized service providers. So let us talk about what to consider when choosing an outsourcing partner for your prior authorization needs.

  • Evaluate potential outsourcing partners by considering factors such as experience, expertise, technology, and cost.
  • Maintaining clear communication and strong collaboration is crucial for successful implementation.
  • Look for client references and a proven track record.
  • Look for a service provider with demonstrated experience in working with SNFs.
  • Look for add-on RCM services like denial management and accounts receivable support for added flexibility.
  • Free trials and non-binding contracts are an added advantage. This lets you try out the service without significant risk.
  • Ask about insurance coverage for your practice.
  • Look for established data security measures and IT infrastructure.
  • Choose a partner who can help with the appeals process in case of claim denials.

Failing pre-authorization requirements can lead to both soft and hard denials. Our experience of working with every major public and private payer allows us to not only reduce denials but also appeal them efficiently.

Prior Authorization for Skilled Nursing Facility Practices

What makes us the best prior authorization service provider for your SNF?

  1.  Dedicated pre-authorization and verification specialists
  2.  80% reduction in operational costs instantly
  3.  Real-time eligibility checks & fast authorization
  4.  100% prior authorization submission on the same day
  5.  Increase rate of completed requests by 1.5 – 2X
  6.  No Binding contracts
  7.  100% HIPAA-HITECH compliance
  8.  Rapid claim status analysis in denial management
  9.  Turnaround time less than 48 hours
  10.  Low service fees with no hidden cost
  11.  100’s of client references across the country
  12.  Tenacious payer outreach and appeals support
  13.  Dedicated account manager and custom reports
  14.  Highest productivity metrics in the industry

Want to know how we can help your SNF meet medical necessity criteria or beat utilization review for SNF care? Talk to our expert today and transition to a quick, effortless prior authorization experience.

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