In today’s economy, everyone is looking to save money and reduce costs, including insurance companies. This has translated into an increasing level of scrutiny when it comes to ordering nuclear imaging studies.
Pre-authorization is now an accepted part of the process, but the requirements and rules are getting more and more complex. In this post, we’ll take a look at ways to better navigate the process.
The pre-approval process
The pre-approval process is used by health insurance companies to verify that certain drugs, procedures, and services are medically necessary before they’re completed.
The quickest way to gain approval is through strict adherence to appropriate use criteria, but it also requires detailed, clear, and complete documentation in the patient’s clinical record.
Documented records should include the patient’s chief complaints, diagnosis, and the results of prior testing that are consistent with a particular treatment plan.
Major roadblocks and how to avoid them
One of the major hurdles is the amount of time that pre-approvals consume and thus detract from other patient-centered tasks in the office. It’s important for staff to have all the information handy before they start the process. The insurance company will have detailed questions, and the staff will need to provide the appropriate answers in a timely manner.
If an insurance company representative senses any lack of confidence, disorganization, or hesitation on the part of the office staff, they can use that to their advantage, which can quickly slow down the approval process.
It’s expected for insurers to require additional information, and sometimes a peer-to-peer review, when the conversation offers up the opportunity to ask for more. You need to be prepared for the possible roadblocks ahead of time.
If your organization is large enough, staff members tasked with managing pre-authorization can work at developing relationships with insurance representatives from particular companies. Leveraging that relationship and specific payer protocol is a smart idea. Chances are they’ll have a higher rate of success because they’ll know what the insurer is looking for and how to manage it.
The benefits of outsourcing pre-authorization
Frustration and the time investment are some of the most common reasons a practice gives up pursuing in-house pre-approval. To combat those hurdles, many practices outsource the approval process to a third-party, like MDBoss for instance, who specializes in pre-certification.
For a practice that lacks the manpower, does not have experienced staff, or the time to spend on the phone with insurers, it can be a cost-effective solution. Many outsourced providers charge based on a per-study basis so even small clinics can leverage the service without worrying about minimums or expensive retainers.
The insurance landscape is continually changing. Many insurers are hiring third-parties themselves to manage their approval process. There is also a push from some insurers, like Humana, BCBS, and Cigna, for locations to become approved test sites. It requires a lengthy summary that includes camera serial numbers, staff credentials, certifications, and other key information, that can easily overload small practices.
The pre-certification or pre-authorization process is an essential part of the services that a physician’s office provides to their patients. There are ways to make the process run smoother, but it takes time, dedicated staff, and a lot of patience.
If your in-house attempts are not producing the desired results, determine the most common hurdles and work quickly to overcome them. It’s in the best interest of your business, your patient’s health, and their financial well-being.
