Top 5 Mistakes in Claims Management – And How to Avoid Them
Claims management accuracy and efficiency are crucial for hospital billing, accounting and finance professionals. However, common missteps can cause...
The prior authorization process stands as one of the most intricate and resource-intensive tasks faced by healthcare providers today. It has been a pervasive issue in the industry for years, and there has not been much collaboration or headway made to make this process smoother for patients, providers or payers.
The complexity of prior authorizations is not just an administrative issue—it has real consequences for patient care, causing delays in treatment and sometimes even undue distress. But within these challenges lie opportunities for transformational efficiency.
Here's how healthcare providers can improve the prior authorization processes to minimize its burden, ensure payments for services rendered and ultimately enable better patient care.
1. Verify prior authorization status
Your teams have enough work to do, and every task matters. Before leaping into the prior authorization process, ensure you are not doubling your efforts. Take proactive measures to confirm whether a prior authorization request has already been made and is in place. This is a crucial step, saving time that's otherwise lost in redundant processes.
Look to innovative solutions that turn away from traditional phone or fax confirmations and utilize payer portals or secure digital communication platforms. These avenues not only streamline the confirmation process but establish a clear and trackable dialogue between providers and payers. They can clearly outline which procedures are financially cleared and which ones require further intervention, allowing teams to work smarter, not harder.
2. Optimize prior authorization request submission
Submitting a prior authorization request doesn't have to be mired in tedious, manual processes. Leveraging automation tools can convert days of waiting and phone tag into a faster and more reliable submission process.
By implementing an electronic, interoperable system, healthcare providers can quickly access payer requirements, gather necessary documentation and submit it all through a more streamlined digital channel. This not only reduces processing times but cuts back on the risk for errors that come with manual input.
3.Handle denials and appeals with agility
Even with the best laid-out plans, denials happen. But appealing these denials should be anything but sluggish. Every denial requires a prompt, well-documented appeal that explains the case for medical necessity with precision and clarity. Handling bulk appeals with similar cases affords an organization operational efficiency and can also hold payers accountable for payment on services rendered.
RELATED: The Growing Challenges of Hospital Denial Management
Best practice organizations harness resources that assist in forming strong, evidence-based arguments for appeals. They tap into industry-knowledge databases, collaborate for peer-to-peer reviews and draft persuasive appeals that align with state insurance board standards. Specialists can also be engaged to provide authoritative opinions, should the situation escalate.
“When leveraging a prior authorization solution, for example, taking information from past claims, as well as keeping tabs on the latest payer bulletins, should afford a near real-time rules engine so stopgaps for documentation are in place,” said Jonathan Wiik, VP of Healthcare Insights at FinThrive.
4. Acquire prior authorization approval efficiently
Following submission, chasing payer responses can be time-consuming. Instead, utilize systems that provide real-time status updates, that can notify you upon payer review completion or even proactively nudge payers at predetermined intervals. This can escalate the efficiency of acquiring prior authorization approval and ensure that treatments are not alarmingly postponed.
Opt for technologies that facilitate direct follow-ups and additional information exchanges without the typical paper trail. Clear, transparent communication channels can prevent unnecessary delays, enhancing the speed at which patients receive necessary care.
Providers who adopt these automated workflows and leverage the right technology will lead the charge toward a more efficient, patient-centric healthcare future, while also safeguarding revenue for a stronger bottom line.
Learn more about how to submit cleaner claims and prevent denials with FinThrive.
