What Is The Authorisation Process In Medical Billing?

What Is The Authorisation Process In Medical Billing?

The authorization process in medical billing identifies medical necessity without compromising patient care. Therefore, achieving a streamlined operation.

The authorization process in medical billing validates medical necessity, also known as prior authorization and pre-authorization. The dental practitioner obtains prior approval before undertaking costly procedures, diagnostics, prescription medications, and medical devices. Failing to secure proper pre-authorization can lead to claim denials, partial payments, and required follow
ups that ultimately affect patient care.

At Capline Services, the team effectively manages the revenue cycle health to provide optimal support through integrating authorization tools with the practice management system, which guarantees fast payment. The practice validates eligibility, prior authorization, and insurance coverage before each patient's visit.

Importance of Authorization Service

  • The authorization provides power to the billing process.
  • It reduces the need for follow-up and eliminates unnecessary denials.
  • The authorization is mandatory before proceeding with procedures and treatments, especially for non-covered services by the patient's insurance. It develops trust within the patients and increases the chances of claim payment.
  • Correct ICD-10 codes with the patient's diagnosis enable the insurance company to approve authorization for the procedure.
  • Practices can avoid delayed payments, claim denials, and the hassle of rescheduling appointments by collaborating with Capline Dental Services for exceptional support to empower practice efficiency.

Challenges with the Authorization Process in Medical Billing

Navigating prior authorization is critical despite its challenges. The American Medical Association (AMA) states that it gets overworked, and they back this research stating that 89% of practicing doctors mentioned that prior authorization has a negative clinical impact, and 33% raise a serious adverse event for a patient in their care.

The associated cost delays in patient care and disruptions lead to problems that demand attention and proactive solutions. The study says 94% report care delays where the treatment requires prior authorization, and 78% report that sometimes the authorization leads to treatment abandonment. It causes an administrative burden to the practitioner.

Secure authorization from the insurance company is crucial as and when the treatments get identified. The patient and the practice must know the approval process and its involvements. If the approval gets denied, the practice must work on alternative treatment options, ensuring the patient receives proper care without delay.

It is unfortunate to say that 1 in 4, nearly 27% of prior authorizations are always or often denied, leading to provider burnout. The authorization appeal process has around an 18% chance of getting approved. The providers feel that the patient care cannot wait for the PA approval.

Authorization Process in Medical Billing Submission Request

The provider can submit the authorization request either electronically or manually. Each insurance companies have different request requirements. However, a few universally essential that improve the chances of approval are listed here:

  • Patient demographic details such as patient's name, DOB, and insurance ID number,
  • Provider details- address, Tax ID number, National Provider Identifier (NPI) Number, and contact details,
  • Service Location with address, Tax ID number, NPI Number, and contact details, • Correct CPT/HCPCS codes,
  • ICD code and description, and
  • For inpatient requests regarding the length of hospital stay.

Moreover, the insurance company can request additional documents as and when needed. That proactively enhances the chances of successful authorization without compromising patient care.

Authorization Process in Medical Billing Is Pending

Pre-authorization is essential for complete reimbursements. It might lead to delays, denials, or reduced payments. Delays in PA can lead to out-of-pocket expenses for the patient that impact the patient-doctor relationship. Predicting all the causes of claim denials is impossible. Consulting Capline Dental Services can streamline operations that reduce costs, manage staffing challenges, develop growth opportunities, and elevate patient care.

How can practice prevent claim denials about Prior Authorization?

Pre-authorization is pivotal in insurance verification, but that doesn't assure reimbursement to avoid claim denials due to pre-authorization, the dental practice can follow the below-mentioned strategies:

  • Authorization Request in Good Time
    The authorization request before the treatment is a proactive approach to obtaining an authorization number to confirm reimbursement.
  • Enter Authorization Number
    For submitting claims, the dental practice must include the authorization number, if applicable, as a standard procedure to support documentation and reduce the chances of rejection by following the protocol.
  • Verify Correct Codes
    Correct coding is a crucial step to prevent claim rejection. Verifying the CPT/HCPCS code's accuracy is necessarily related to treatment. It is non-negotiable and results in costly outcomes.
  • Look into the Denials
    Denied claims mostly have clear reasons. For error-free submissions, contact the payer for clarification, which can lead to potential reimbursement.

Additionally, outsourcing the insurance verification process to Capline Dental Services can confirm authorization without failure.

Let's dive into how the practice can improve the prior authorization process!

Improving Authorization Process

  • Accurate documentation can save time in the lengthy prior authorization process. Most practitioners avoid this step and try to cut corners in PA processes, which results in decline. It is better to do it correctly the first time as it is a cost-effective strategy.
  • The time-consuming prior authorization can take several days or weeks to get approved. The practitioners must automate the PA between the provider and the payer for quicker turnaround times.
  • Another way to accelerate the authorization process is to restrict the number of services that require approval. The staff and the provider can ensure prior authorization requirements before rendering services.
  • Creating a list of procedures or medications that require pre-approval is an effective strategy for identifying the requirements. For instance, referring to PA guidelines or consulting electronic health records necessitates authorization.
  • Outsourcing to seasoned professionals like Capline Services can speed up all related processes and frees the staff to concentrate on patient care.

How Capline Services Can Help with RCM

  • The team of experts consists of developers, trainers, and consultants who support prior authorization in medical billing.
  • They offer tools like dashboards, automation, and workflow design to improve the practice's financial future.
  • At Capline Services, the team ensures the practice knows everything about authorization to avoid upcoming issues.

Related Posts

Follow Us For More!

Connect with us on our social media handles for industry insights, service updates, and tips to optimize your healthcare practice.
magnifiercrosschevron-down