When running a medical practice, having to overcome prior authorization requests can be one of the most time-consuming and seemingly unnecessary hurdles you’ll have to overcome.

Still, it goes without saying that prior authorizations are absolutely necessary to obtain from a patient’s health insurance company before you begin performing any procedures or treatments. As such, it’s absolutely paramount that you have a clear understanding of how this process works in order to ensure timely reimbursement and generally reduce the financial burden – both for your practice and your patients.

So, throughout this article, we’ll be taking a look at why insurance companies actually require prior authorization, as well as guiding you through the overall process. Let’s get started with some simple background information on the topic.

Understanding The Pre-Authorization Process

Pre-authorization is essentially just a process that insurance companies like to demand before certain health care services can take place. Understandably, this may seem like just another one of the many bureaucratic processes you have to perform, but there is actually an important underlying reason here.

Basically, insurance companies will require pre-authorization in order to ensure the appropriateness of care and keep costs in check. Aside from this, they’re also just looking to avoid any potential fraud or unnecessary procedures.

Generally speaking, this sort of paperwork is necessary for any healthcare provider looking to establish a clear line of communication with the insurers.

The Role of Pre-Authorization In Healthcare Cost Control

It’s no secret that healthcare costs in America are on the up, and, as a matter of fact, insurance companies actually play quite a critical role in terms of effectively managing these costs. This sort of process helps them to evaluate the medical necessity of a procedure, so the overall goal here is to ensure that resources are always properly allocated.

Key Steps to Successfully Obtain Pre-Authorization:

Now that we’ve got an understanding of why this process is important let’s take a look at how your practice can actually obtain pre-authorization.

Gathering Essential Information

To navigate through this process smoothly, you’ll have to familiarize yourself with a few relevant terms and conditions, including things like specific pre-authorization requirements or limitations.

Ultimately, knowing the scope of coverage lets you see which procedures actually require pre-authorization, as well as avoiding any potential issues when it comes to reimbursement.

Communicating With Your Patients

As you’re undoubtedly aware, open communication between you, as a healthcare provider, and your patients is integral, but this goes for securing pre-authorization, too.

Just make sure your patients have a firm understanding of their specific insurance policies and what their responsibilities are when it comes to pre-authorization. In addition, you’ll also want to maintain any medical documentation that’s able to support the medical necessity of the procedure you’re treating them for.

Understanding The Insurer’s Pre-Authorization Requirements

Each insurance company has its own process and requirements when it comes to prior authorizations, so ensure you’re taking the time to understand these requirements so you can prevent any unnecessary delays.

Furthermore, you might also wish to contact the insurance company directly so you can ask for a clear explanation of their pre-authorization process. Try to inquire about which forms and documents are necessary as well as any other information they may require.

Timely Submission

Unfortunately, time is generally of the essence when it comes to pre-authorization, with most insurance companies usually having specific timeframes in which the requests are submitted.

You’d never want to miss this window, so ensure you familiarize yourself with these timelines when contacting the insurers and submit your request well in advance of the treatment. This basically just means their submission has ample time for review, which can be pretty helpful for preventing denials.

How PMN Can Help

Naturally, the whole prior-authorization process can be a handful for a primary care provider that’s already juggling various responsibilities – not to mention the overall strain on your time.

As a result, many similar-sized medical practices choose to partner with third-party medical billing companies, such as PMN, to bear this responsibility for them.

PMN brings a wealth of expertise to the table in this field, not only following all the relevant clinical guidelines but also ensuring your practice remains compliant with organizations like the American Medical Association (AMA).

Whether it’s by streamlining the prior-authorization request or by minimizing denials for your practice, PMN can help you obtain approval quickly and increase your general efficiency.

So, if you’d like to learn more about PMNs services, don’t hesitate to contact one of their staff members at (949) 215-5055. You can also visit their office in person in Laguna Hills, Orange County, California if you’d prefer an in-person chat!

FAQs

How Long Does The Pre-Authorization Process Typically Take?

The duration of this process usually varies based on how complex the procedure is as well as what the insurance company’s specific policies are. Still, it can generally take anywhere from a few days to a few weeks to receive a decision. So, to avoid delays, follow up with your insurance company regularly and ensure all requested documents are submitted properly the first time around.

What Should I Do If a Pre-Authorization Request Is Denied?

If a pre-authorization request is denied, you don’t need to panic; just review the insurance company’s explanation of benefits (EOB) to understand the reason for the denial. It could be due to insufficient documentation or medical necessity concerns, so consider gathering additional supporting evidence in order to back your request up.