Every practice knows that handling a prior authorization case load can be time-consuming and burdensome. Not only do payers require you to spend endless time filling out forms and even sitting on hold when you call, but they often end in erroneous denials. In fact, one OIG report found that an alarming 13% of Medicare Advantage prior authorization denials should have been paid — which means practices must be diligent in tracking them and immediately appeal when needed.
The best way to cut the burden on your practice due to prior authorization red tape is to employ a few key strategies. Check out five tips that may help.
1. Name One Prior Authorization Point Person
To keep prior authorizations from burdening half of your office, it’s essential to put one person in charge of handling this responsibility. This can solve a few issues. First, it ensures that you aren’t doubling work by having one staffer submit a prior auth request to one department while another team member submits it to a different department. Instead, the point person knows where that prior auth has been every step of the way and what the status is.
It also frees up other team members’ time so while one person is handling prior authorization requests, everyone else can take care of other responsibilities. Whether you appoint your coder, your revenue cycle manager, your front desk manager or someone else, the choice is up to you, but it’s better not to have too many cooks in the kitchen when it comes to prior authorizations.
2. Create a Master List of What Requires Prior Authorization
While not every service and medication can be identified on a master list at your practice, it’s a good idea to create a list of at least 10 commonly billed medications and services which require prior authorization.
That list will depend on your specialty, the type of work that you do, the type of patients that come into your office, and the conditions you frequently see. Take that list and then cross reference it against the payers you’re contracted with to generate the items that are going to trigger prior auth requests so you can easily reference them.
Once you have that master list, make sure it’s integrated with your EHR and segregated by payer so everyone has access to it.
3. Create an Internal Process
Every practice should develop an internal process to consistently document, in the medical record, the data that is required for prior authorizations so you can easily respond to payers and demonstrate why patients need the service. This should be accessible by everyone on your staff. Even though one point person will be handling your prior authorizations, anyone should be able to see, in real time, where a prior authorization stands.
4. Regularly Follow Up
Unfortunately, handling prior authorizations is not a “set it and forget it” type of responsibility. You’ll need to follow up with payers regularly to see where your prior auths stand. If there’s a holdup, identify it early so you can fix it rather than waiting for a payer to tell you what’s causing the delay.
Payers will always push the envelope in terms of timelines and denials, so it’s up to you to stay on top of how your prior auths are moving through the system.
5. Appeal When Necessary
If you’re tracking your prior authorizations closely, you’ll identify denials swiftly, at which point you should appeal when warranted. If this happens, you should submit a concise, well-articulated appeal with all of the supporting clinical information necessary to demonstrate why the payer should reconsider its decision.
If necessary, you may need to speak with the payer’s medical director during the appeal process to clear up issues and get your prior authorizations approved. As long as you’re tracking the process and following up, you should be able to do this in time for your patients to get the services and medications they need to stay healthy.
Don’t get tripped up by the myriad rules surrounding prior auth payment. Let healthcare attorney and expert Osato Chitou, Esq., MPH guide you during her online training, Prior Authorization Final Rule: Tactics to Fight Back and Win. Register today!
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