Seamless Access to Care

Management Process

Prior authorization is a management process used by insurance companies to determine if a prescribed product or service will be covered and it’s also one of the most difficult tasks that a medical practice must take on. This process can be used for certain medications, procedures, or services before they are given to the patient. It is a challenging, and expensive process because it consumes so much of your office’s time and resources. Because of this, many healthcare systems and hospitals decide to outsource the work to an experienced medical billing company

Prior authorization
services we offer:

  • Prior authorization determination and requirements.
  • Submission of authorization paperwork to insurance.
  • Follow-up on the authorization request.
  • Notification and resolution of rejection of authorization application.

How does Prior Authorization work?

Getting prior authorizations approved involves many people – primarily patients, healthcare professionals, and the patient’s health insurance companies.

Prescription Prior Authorization

When it comes to medication prior authorization, the process typically starts with a prescriber ordering medication for a patient. In many cases, providers may need to directly call the insurance companies, which often requires long periods of waiting and maybe even persistent calls for a couple of days.

Medical Prior Authorization

The prior authorization process begins when a service prescribed by a patient’s physician is not covered by their health insurance plan. Communication between the physician’s office and the insurance company is necessary to handle the prior authorization.

Provider Opinion on Prior Authorization

Many physicians are not fond of the growing number of prior authorizations needed by insurance companies in recent years. A 2019 study from the American Medical Association reported that 86% of physicians believe that prior authorizations have increased in the prior 5 years.

Understanding the impact of Medical Necessity on Pre-Authorization

When healthcare providers fail to obtain the proper authorization and the payer (insurance company) denies payment, the healthcare organization must decide whether to bear the expense or claim it from the patients. Procedures not covered by the patient’s health plan are clearly specified and acknowledged during the verification process. When a patient receives benefits or services that are not covered by their insurance plan, they must pay for the services. When the claim are denied as a result of the provider’s inability to obtain approval, they are obligated to pay for the expense themselves, resulting in a revenue loss that affects the entire revenue cycle.

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14430 Ocean Point, El Paso, TX 79938

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