How Prior Authorization Denials Happen

The American Medical Association or AMA reported that out of 1,000 providers…940 saw delays in care due to prior authorizations or PA. Even worse, eight in ten said their patient abandoned treatment while waiting.
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It doesn’t matter if you manage a large scale healthcare facility or a neighborhood practice, statistics like that don’t bode well for your bottom line.
The truth is that denials make it hard for your organization to operate because they have a direct impact on the revenue that helps keep your lights on.
Yes, in a perfect world healthcare organizations see patients and administer treatment. Yet, the reality is much different. Managing and submitting claims is an unavoidable aspect of the healthcare space…which inherently also means the same is true for the reception of denials from payers.
It doesn’t have to be this way…and prior authorization denials don’t have to be such a common occurrence either. But in order to stop prior authorization denials from happening…we have to know WHY they happen.
The truth is…insurance companies are out to get you. They don’t care one way or another, they deny your claims on a whim because they feel like it. I’m kidding…mostly.
In a perfect world, practices care for patients, patients have health insurance and health insurances pay practices for the services they rendered.
If you’ve worked in healthcare for a while now, you know that that’s not the case.
You see, prior authorization is one of the first steps that should occur before a medical professional provides or performs a service on a patient. To be more specific, before any servicing happens, a doctor needs to ensure that a patient’s insurance provider will pay for it. Prior authorization also applies to prescriptions in most cases.
Anyway, prior authorization happens by either calling a payer or contacting it electronically.
Let’s look at an example. This screenshot comes from Healthcare Partners. It has an entire section of its website devoted to explaining its prior authorization process. It confirms the point from earlier, in most cases, PA happens by speaking with a representative of a provider or electronically.
Prior authorization is a step that happens ideally before a patient receives any form of treatment…that way there wouldn’t be any denials.
However, the reality of it is much different.
If you scrolled down from the page that the previous screenshot was on, you should stumble upon this section of Healthcare Partners’ webpage.
You see, payers place time requirements on prior authorizations. In this case, for routine procedures, Healthcare Partners requires authorization for services within 14 days of services rendered.
That deadline isn’t unique to Healthcare Partners, many other healthcare insurances also use 14 days.
Sometimes insurance payers provide their exhaustive list of PA services, prescriptions, etc. online like with the example screenshot above from Paramount Healthcare. Paramount Healthcare’s PA document is a 14-page long table with what seems like thousands of rows.
After all of this, the question still remains, “How do prior authorization denials happen?”
Well, prior authorization denials happen when the provider doesn’t have PA from the patient’s insurance organization. Maybe the payer rules changed unexpectedly…maybe the payer is new to the practice so the payer’s PA requirements aren’t familiar…maybe your staff of billers can claims managers can’t keep up with the changes and additions to so many payer plan precertification rules…maybe your practice does not have the capacity to handle prior authorizations and can’t find a reliable vendor to outsource to.
Yes, the prior review process is frustrating…not to mention the fact that the expense of denied claims results in receivable bottle necks and write-offs. But, that doesn’t mean that you should give up hope. There are ways to avoid this type of denial…and even if you still receive them after putting in place several safeguards, this type of denial can be overturned. Now that we have some common ground as to how prior authorization denials happen…we’re at a good starting point on how to fix them.
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#PriorAuthorization #denials

[@leonardopatrizio]

I like how fast she talks, otherwise i get too bored waiting for them to make their point and i zone out. And i forget i can speed up playback in the settings

[@MrSmith-jj9te]

An insurance provider should not be allowed to refuse nor dictate what procedures a patient needs that’s been ordered by a doctor.
Bureaucratic/ corporate trash like this does absolutely nothing, but hinder patient care while simultaneously putting patients lives and welfare in the hands of corporate fools. Insurance providers are not licensed physicians.
The only thing worse than some corporation dictating medical decisions at the expense of an individuals well being are a bunch of politicians attempting to dictate medical decisions at the expense of an individuals well being.
Neither one should have a right to dictate such aspects of life period. These people and their morally bankrupt entities are not doctors. When a doctor orders a medical procedure insurance should be forced to pay by law because that’s entire point of having insurance in the first damn place.
The medical industry wouldn’t be so deludedly expensive to begin with if it wasn’t for the never ending bureaucracy and the self-serving laws of greediocy fathered by a corrupt corporate owned government that allowed such greed to manifest with field of medicine.
Instead of having laws that prevent and punish greed. Our backwards ass society has laws that encourage and protect it.
Made so by the worlds largest criminal enterprise called the government. A corrupt cancerous institution that hypocritically hides behind the color of law and the one-sided laws of ignorances it creates to protect and serve the cancer it has become.
The wealth inequality gap wouldn’t be as wide as it is today without the obese hand of government pulling the strings. None of these so called big business industries could have reaped such vast amounts of profits and wealth without the diseased hand of government pulling the strings protecting and serving the few at the expense of everyone else but their own.

[@dejavu4560]

Could not understand what she says

[@vt7814]

You talk waaaay toooo fast. Hard to understand.