Town Hall – Prior Authorization

Slides:

View June 8th^LJ Prior Authorization Bennie Jones and Bryan Thomas via Google Drive

View June 8th^LJ Prior Authorization Bennie Jones and Bryan Thomas via Dropbox

1. What core information do OHPs need for getting prior authorization?
2. Who should gather the information?
3. What are the differences between PT authorization, MRI, provider specialists?
4. What is the expected time for the process?
5. Who determines the need for prior authorization?
6. What can a program do to shorten the time?
7. What is the benefit of using additional software programs in addition to your EMR for the PA process?

Audio:

Resources:

Swiftivity Provider Flyer 010121 via Google Drive

Swiftivity Provider Flyer 010121 via Dropbox

In today’s fast-paced healthcare industry, efficiency is of utmost importance. One area that often poses challenges for healthcare providers is the process of obtaining prior authorization for certain services. Prior authorization, also known as pre-authorization or pre-certification, is a vital step in ensuring that healthcare providers receive payment for specific services before delivering them to patients.

In this blog post, we will delve into the intricacies of prior authorization and explore strategies to streamline this process. We will draw insights from a recent script, titled “Pre Authorization for Physical Therapy Radiologist Physician Specialist,” which features a discussion between industry experts Benny Jones, Brian Thomas, and Mike Schmidt. These experts share their knowledge and provide valuable insights into navigating the prior authorization landscape.

Understanding Prior Authorization
Prior authorization serves as a cost control process implemented by health plans and providers. It requires physicians and healthcare professionals to obtain advanced approval from the health plan before delivering specific services to qualify for payment coverage. This process is essential in occupational health, workers’ compensation claims, and may also be necessary in personal health insurance settings, such as urgent care.

Core Information for Prior Authorization
Benny Jones, President and CEO of Risk Management Solutions of America, advises starting with the basics when it comes to obtaining prior authorization. The 272 or 278 format is a foundation that facilitates the process. Additionally, payers’ information and determining the most effective way to send the request to the payer are crucial. Including payer rules and state guidelines, especially for workers’ compensation, ensures compliance and reduces unnecessary delays.

Understanding the Different Requirements
Physical therapy, radiology, and physician specialist services have distinct requirements for prior authorization. Benny Jones emphasizes the importance of prescriptions in many states. Having the referring physician’s information and any necessary patient information contributes to a smoother approval process. It is vital to understand and adhere to payer-specific guidelines and codes while providing all necessary records for a comprehensive evaluation.

Navigating Network
Working with physical therapy networks may present challenges. Benny Jones suggests negotiating with networks to potentially improve parameters such as visit count and cost. Larger practices may have increased negotiating power, but smaller practices can explore aggregation to amplify their voice. Understanding the network’s role and responsibilities and where to send requests will help streamline the process.

Timeframe and Automation
According to Brian Thomas, delays in the prior authorization process are common, with physicians often waiting at least one business day for a decision. This can lead to care delays and even treatment abandonment. The survey also highlighted that physicians and their staff spend an average of 16 hours per week on prior authorizations. To reduce these costly delays, automation is crucial. Integrating electronic submission of requests, timely communication between stakeholders, and simplifying the process through vendor support can significantly improve efficiency.

Building Relationships and Monitoring Outcomes
Prior authorization success can be attributed to strong relationships with insurance providers. Mike Schmidt emphasizes the importance of trust in the referring physician and the reputation of the clinic in securing approvals. Monitoring denials and their causes, along with maintaining transparency and customer service with patients and payers, helps build a positive reputation and enhances the likelihood of getting approvals.

Benefits of Additional Software
Additional software programs that integrate with existing Electronic Health Record (EHR) systems can streamline the prior authorization process further. Brian Thomas advises healthcare providers to discuss API integration with EHR vendors to pull relevant patient information automatically. Such software allows for a centralized approach to prior authorizations, facilitates timely communication among stakeholders, and more effectively manages the entire process.

Streamlining the prior authorization process is crucial for healthcare providers aiming to deliver efficient and effective care. Understanding the core requirements, building relationships with insurance providers and client companies, implementing automation, and utilizing additional software are key strategies to achieve this goal. By optimizing the prior authorization process, healthcare providers can reduce administrative burden, save time, improve patient care, and enhance their overall operational efficiency.