Health insurance companies require prior authorization, often known as pre-authorization, to make sure that expensive operations are medically essential. Before beginning any treatment, diagnostic, medical equipment, or prescription drug, doctors or other healthcare providers must have prior approval. In medical billing, improper pre-authorization increases the risk of partial payment, follow-up requirements, and denials.  

By assisting practices in managing the health of their revenue cycle, I-conic Solutions enables them to better support the health of their patients. Practices can integrate prior authorization tools with their practice management system to provide patients with faster, more accurate, and dependable service. This is the most effective approach to guarantee that your practice management system is up to date with insurance coverage, eligibility, and prior authorization requirements before a patient’s.

Pre-authorization speeds up the invoicing process by lowering the number of denials and follow-up requests. Prior permission should always be sought before undergoing treatments or procedures that may not be reimbursed by their health insurance provider. Prior authorization increases the likelihood that a claim will be reimbursed and simplifies the medical billing process for clinics.

Verifying the need for prior authorization should be done as part of the pre-registration procedure. Once the insurance eligibility of the patient has been established, the insurance verification team should confirm if prior permission is required. Potential CPT codes that will be invoiced in addition to the ICD10 codes of the patient’s diagnosis must be reported to the insurance company if prior authorization is required. After that, the insurance provider will determine whether to approve billing for the surgery. The procedure should be scheduled with the patient once this authorization has been obtained.

Claims denials, postponed treatments, rescheduled appointments, and other issues are prevented when the correct procedures are followed. The practice management experts at I-conic Solutions provide staffing, workflow, configuration, training, and support.  

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Medical billing prior authorization can be difficult for a few reasons. In the opinion of the American Medical Association (AMA), it is overused. Although there are additional factors to take into account, their main worries are related to the study they have done on the related expenses, delays in patient care, and interruptions brought on by prior permission. 

Determining all of the medical codes, diagnoses, and other details pertaining to treatments and procedures presents difficulties for the revenue cycle teams. Of course, there may be further mitigating circumstances. Here are a few difficulties that practices could run into while requesting pre-authorization for medical bills.   

Once the patient’s treatment needs are determined, it is still imperative to request authorization from the health insurance provider. The patient and the practice must be aware of the approval status of the permission. A alternate course of treatment will need to be determined upon by the patient, practitioner, and authorities if approval is not granted.

If the insurance company is not contacted for pre-authorization when invoicing for medical services, a claim may be refused, postponed, or only partially accepted with lower reimbursement rates. The medical organization may often cover all or a portion of the expense. Additionally, they have the option to resubmit the claim along with an explanation of their decision to appeal. That does not guarantee that the claim will be granted payment, though.  

While it is hard to predict every scenario that could result in a claim being denied, there are things that can be done to lessen and even prevent denials. Here are some recommendations for handling the prior authorization procedure: 

Most technical and human errors that could cause claims to be delayed or result in a claim being denied entirely or partially can be avoided by adhering to these best practices. I-conic Solutions may assist in cost reduction, workforce shortage management, improving a company’s growth position, and enhancing patient care for an organization through revenue cycle consulting. 

The NextGen consultants, developers, and trainers at I-conic Solutions can assist with the medical billing prior authorization procedure. I-conic Solutions provides the resources you need to support and enhance your financial future, from automation and workflow redesign to revenue cycle consulting and dashboards. Find out now how we can assist.   

Prominent in the healthcare industry, I-Conic Solutions is a trailblazer in streamlining and optimizing your RCM (Revenue Cycle Management) and medical billing revenue system requirements. As a proficient service provider, we ensure that our state-of-the-art accessibility and usability are available around-the-clock to keep our clients in a creative environment. We’re constantly available, with project managers facilitating a simple and painless access process.

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