Why is Pre-authorization in Medical Billing Important?
To ensure a seamless process of pre-authorization in medical billing, it is vital that the payer sees to it that the services are included in their insurance before having access to them. So, in healthcare, it is quite important that the user pre-authorizes every service provided by the hospital. Once the user is found eligible to avail an Insurance, the next step would be pre-authorization in Medical billing.
What do you Understand from the Insurance Eligibility Verification Process?
Someone who is unaware of what exactly the Insurance eligibility verification process means, might fall into the shackles of fraud providers who know how to suck money from innocent people. Always have an idea that insurance eligibility verification is the procedure of verifying a patient’s insurance under three sub-points:
- Coverage status
- Active/ Inactive status
- Eligibility status
Except in case of facing problems in these above-mentioned criteria, no other reason is valid for someone to be not eligible for withholding insurance. After one is done passing the insurance eligibility verification process, the next unavoidable step is making sure that certain products or services are covered by your plan or not. In case the services are not included in your plan, the payer has to get prior approval or pre-authorize the particular desired services, medications, full body scans, etc. These special services require pre-authorization because they are mostly on the costlier side, and the healthcare providers have to get approval from the patient’s health insurance company before asking them to cover the charges for the same.
Frequent Challenges of Pre-Authorization in Medical Billing:
- It is essential for the providers to fill in the required credentials correctly before filing for pre-authorization.
- Any sort of mistake in the name, age, date of birth, phone number, fax number, tax ID number, or address might turn out to be the reason for the rejection of the claim.
- The filing process should be carried out fast as the tedious process of pre-authorization might take up a lot of time and result in keeping the patients aloof from the care they need.
- Normally, these approvals are centered around the insurance scheme that the patients possess. If the insurance does not cover certain services, then the pre-authorization might get delayed or denied.
- Disapproval of pre-authorization can also be the result of harmful side- effects or an appropriate need for a drug.
When the insurance providers fail to give particular approvals and the services are denied because of loopholes in the insurance eligibility verification process,it comes upon the hospital to make the final decision whether to take the cost on them or collect from the patients.
Sometimes,the hospitals send bills after the treatment is done but that might hamper the hospital’s reputation. Therefore obtaining pre-authorization at the right time is quite essential in the medical billing process.
Importance of Pre-Authorization in RCM:
The pre-authorization in the medical billing process is very important in revenue cycle management (RCM) as before going for costly medications or health care services, the payer should be well aware of the exact amount of money that they have to pay and what is to be covered by the insurance company. An unapproved authorization might end up putting the patient’s life at risk or interrupt the patient’s treatment process.In worst case scenarios, when there is an emergency situation where pre authorizing of medical billing is not possible, the hospital has to take necessary steps and obtain the required authorizations.
Mandatory Steps to be taken in the Pre- Authorization Services:
- Cross checking during the verification process to have an idea about the services to be covered by the insurance company.
- Having a detailed and perfectly documented record of all necessary information.
- Understanding the services and how the insurance company works.
- Giving proper instructions to staff and employees in case of emergency situations.
Conclusion:
The prior authorization services are definite assets to the cost bearers as well as the insurance companies. Even though people nowadays do not believe in pre-authorization in medical billing, it is vital to understand the emergence of having these files beforehand. It really helps the payer to avail of the services by healthcare providers without interruptions in the treatment process.
