Most insurance companies have their own rule, which makes handling prior authorizations tricky. To make things harder, payers often add new services to the prior authorization list each year.
Using a specialized home healthcare billing service can help you manage these complexities and get approvals faster.
Know about hassles of prior authorization in home healthcare billing:
Insurers use prior authorization (PA) to decide if services are medically necessary before patients get them. But a 2022 AMA survey showed that many physicians see PA as a source of wasted time and avoidable harm. In fact, 88% of doctors said the burden of PA is high or extremely high.
To manage this load, 35% of physicians have staff dedicated solely to handling PA tasks. Over 80% said PA caused delays in care, which negatively impacted patient outcomes and even led some patients to abandon treatment altogether.
Fortunately, you can streamline a perfect pre-authorization process by implementing the tips mentioned below-
Perfect tips to obtain prior authorization in your home healthcare billing process:
Know about each payor’s pre-auth policies:
Every insurance company has its own prior authorization form that you need to fill out when prescribing a specialty medication or treatment that isn’t covered under their formulary.
Your practice might have to handle many different forms, each with its own length and complexity. It’s important to take the time to understand these forms and complete them accurately.
Perform accurate coding:
Make sure you report the right diagnosis codes that show why the procedure is necessary. This helps the payer understand the need for the service and can be useful during reimbursement negotiations.
You also need to report the correct CPT codes for all treatment options you're considering. For example, if a home healthcare practice is treating a patient with shoulder pain and is thinking about using either viscosupplementation injections or corticosteroid injections, they should submit the CPT codes for both options. This way, the provider can receive payment, regardless of which treatment is chosen.
Ensure accurate information:
One main reason prior authorizations take so long is that health plans often receive incomplete or incorrect information. When scheduling patients, make sure to verify their eligibility and benefits and check if prior authorization is needed.
You’ll need the patient’s ID number from their insurance card or SSN, their name and date of birth, the type of procedure(s) being scheduled, the tax ID number or NPI of the facility, and the ordering doctor’s tax ID number or NPI. Even small mistakes like a wrong number or incomplete address can lead to denials and extra work for your office.
Using professional insurance verification services can help you set up a reliable verification process for all patients.
Carefully understand payers’ criteria: Payers will only pay for services that meet their specific criteria for medical necessity. It’s important for you to understand what each payer defines as medical necessity.
For instance, Medicare Advantage Contractors use certain criteria to decide if a service or item is medically necessary:
- It is safe and medically effective.
- It is not something experimental.
- It is medically appropriate in the following cases:
- It follows accepted medical practices.
- It is provided in a setting that suits the patient's needs.
- It is ordered and provided by qualified professionals.
- It meets the patient's medical requirement.
When you submit the pre-authorization request, include the patient’s diagnosis and the procedure you're planning. Also, add information about how serious the diagnosis is, the risks of not doing the procedure, and any tests or treatments that have already been tried.
Filling in these details will help prevent extra reviews of medical records, claim denials, and overpayment requests.
Justify the medical necessity of the candidate:
If a patient needs surgery, the surgeon or referring physician can write to the insurance company to explain why the patient needs the procedure. They can also include research or studies to back up their reasons.
Follow proper treatment guidelines:
Make sure you stick to the recommended treatment guidelines for expensive procedures. Insurance companies usually review treatments after they're done to check if they were appropriate, effective, and delivered on time.
They also look at where the treatment took place. If you don't use proven treatments and a claim gets denied, you’ll be the one facing the financial burden.
Obtain PA approval for mundane home healthcare process also:
Before, prior authorization mainly focused on expensive treatments like cancer care. Now, insurance companies also require it for more routine services, including basic imaging procedures like CT scans and MRIs, as well as brand-name medications.
Always visit insurance companies’ websites: You can learn about insurer policies by visiting their website or calling them directly. This information is also included in payer contracts.
Make sure to inform your patients about any policy details that might affect them, so they can discuss it with their insurance carrier and advocate for themselves and you.
Perform daily audits:
Regular preventative audits can help you spot issues and find denial trends for specific procedures. This way, you can fix problems that are causing many of your claims to be denied.
To avoid all the hassles related to prior authorization and home healthcare billing, most mid and small-scaled home healthcare practices, these days, prefer to outsource their end-to-end revenue cycle management to a professional third-party medical billing company.
The best part of outsourcing home healthcare billing to a reputed company like Sunknowledge allows you to fully focus on patient care while; they take care of your entire billing mechanism, enabling you to save operational costs up to 80% and ensure 99.9% billing accuracy.
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