Prior authorizations, or prior approvals, are strategies that payers use to control costs and ensure their members only receive medically necessary care. The cost-control process requires providers to acquire advance approval from payers before delivering specific services or items for a patient.
Payers are increasingly using prior authorizations to lower their costs and improve care quality for their members. But the process of obtaining prior approval for services creates a significant burden for providers.
Prior authorizations may be a major administrative pain point for providers. However, payers are looking at the cost-control method as a key strategy, resulting in greater prior authorization use.
Providers can overcome the burden of dealing with prior authorizations by following the ways given below
Have forms available, either in print or on computers, for the procedures and prescriptions that most commonly require prior authorizations
Use the Web
Check on the payer’s website for any prior authorization criteria they have posted, and submit requests using the website rather than the telephone.
Make the Patient’s Information Available
Be sure the person submitting the prior authorization request has access to the patient’s chart and any other information needed to justify the request
Document the Need
Note in the patient’s chart why they need a particular procedure, medication, or exception to the payer’s requirements.
Follow the Guidelines
Following recommended treatment guidelines increases the likelihood that a payer will approve prior authorization requests.
Learn What Drugs Payers Will Cover
Knowing which medications all your payers cover for common conditions, such as hypertension, and prescribing them whenever appropriate, reduces the need for prior authorizations.
Start Patients on Generics
Insurance companies are made likely to cover a brand-name drug if you start the patient on the generic form, provided one is available in the same therapeutic class and isn’t contraindicated.
Centralize the Process
Designate specific staff members to handle prior authorization requests, even if your practice has more than one site. Then make sure those individuals have access to all patient records and provider’s notes from throughout the practice.
Do a Cost-Benefit Analysis
Find out how many prior authorizations each of your biggest payers required over the last year and consider dropping any whose reimbursements don’t justify the time it took to get the authorizations.
For More Information: https://www.medicaleconomics.com/news/9-ways-ease-prior-authorization-burden