A 360-degree Prior Authorization Approach
Prior Authorization needs to be approached from an aspect of utilization management, specifically prospective utilization review, where an insurance payer looks at a number of factors such as medical necessity, prior treatment, clinical indications, and total cost of the therapy to determine whether a cost-savings could occur.
Utilization management is practised by both insurance payers and hospitals to rein in costs and reduce denials, but in the real world, PA is responsible for 92% of care delays, treatment abandonment, and 853 hours per year of wasted staff time.
Even with staff specifically designated to handle the bulk of the paperwork, insurance filing, and medical prior authorization processes, there is still a great deal to manage here. Not only do they (and you) have to ensure paperwork is filled out completely for every patient, but they also have to ensure each of the precertification is obtained in a timely manner, follow up on requests for more information from the physician, and deal with requested paper work or deal with denials. That’s not to mention the broader-scale tasks like keeping up with policy changes and staying up on training.