{"id":9332,"date":"2022-09-12T20:28:29","date_gmt":"2022-09-12T20:28:29","guid":{"rendered":"https:\/\/risefoc.com\/?p=9332"},"modified":"2023-05-11T21:17:33","modified_gmt":"2023-05-11T21:17:33","slug":"blog-prior-authorization-best-practices","status":"publish","type":"post","link":"https:\/\/risefoc.com\/blog-prior-authorization-best-practices\/","title":{"rendered":"[BLOG] Prior Authorization Best Practices"},"content":{"rendered":"

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By: Donald Drummy, Director of Revenue Cycle<\/strong><\/p>\n

As revenue cycle professionals, we often see the burden prior authorizations cause on our patients and providers.\u00a0 I am passionate about making the process easier to get faster patient care access, but I see the scenarios below all too often.<\/p>\n

Picture it:\u00a0 Your doctor tells you that you have a life-threatening form of cancer.\u00a0 The treatment needed is expensive, and your insurance requires prior authorization.\u00a0 You, the patient, think, \u201cno big deal, I\u2019ll just have my expensive insurance approve the medicine.\u201d Not so fast.\u00a0 Your insurance requires a \u201cpreferred\u201d drug therapy that is less expensive than the therapy your doctor prescribed, which is also known to cause worse side effects and has a more prolonged treatment cycle.\u00a0 Oh, and by the way, it\u2019s because the preferred drug is less expensive.<\/p>\n

Well, your doctor can get the better drug therapy approved, but only after a prior authorization request is initiated and denied.\u00a0 Your doctor must appeal via a peer-to-peer review.\u00a0 Your doctor sets up a time to talk with a doctor from the insurance company to discuss why you need to start on the more expensive drug therapy and avoid wasting time on the cheaper drug therapy.<\/p>\n

Another example may be that you are a patient experiencing back pain for several months or years!\u00a0 After many months of cortisone shots and physical therapy, your doctor decides a surgical intervention is the best course of therapy.\u00a0 Not so fast, my friend!\u00a0 Your insurance company has denied your prior authorization for that spine surgery and wants you to do another 12 weeks of different physical therapy before you have that surgery.<\/p>\n

Prior authorizations have become the bane of existence for patients and providers. \u00a0However, there are ways to mitigate these denials and obtain a first-pass approval rate of 95%+ for your authorizations.\u00a0 Here are some guaranteed ways to have a successful prior authorization process.<\/p>\n

Medical policies for procedures and tests
\n<\/strong>We know insurance will only pay for medically necessary care, so why not make sure their medical requirements are covered before ordering?\u00a0 Knowing the policy allows physicians to ensure they are \u201cchecking all the boxes\u201d regarding insurance requirements for a service to be medically necessary.\u00a0 When possible, it is best to add these requirements into \u201csmart phrases\u201d into your EMR clinical documentation templates.<\/p>\n

The list of third-party administrator websites below is not exhaustive and changes over time, but it is a good starting point for your prior authorization team.\u00a0 Most insurance companies use these third-party administrators to manage their prior authorizations for services.<\/p>\n