Prior authorization, also referred to as preauthorization, is a practice that is used by health insurance companies that requires certain tests, procedures, and medication prescribed by healthcare clinicians to first be evaluated in order to assess the necessity and cost-of-care ramifications before they are authorized.

The prior authorization has many steps and is oftentimes very complex. In today’s post, we will be discussing the differences between the traditional, in-office prior authorization, and having prior authorization services outsourced with a reliable team of prior authorization specialists.

How does the prior authorization process work?

  1. A healthcare clinician determines that a patient needs a specific test, procedure, medication, or device, and then checks a health plan’s policy rules in order to determine if a prior authorization will be required for the course of treatment that is prescribed.
  2. If it is required, the provider will then need to formally submit a prior authorization request form and sign it to attest that the information is true and accurate.
  3. Clinical and healthcare billing systems are rarely integrated, so healthcare provider staff will need to start manually reviewing the rules of prior authorizations for the specific insurance plan associated with the patient. These rules vary from health plan to health plan, and even differ from plan to plan with a specific payer. These rules also change frequently, so a healthcare provider’s administrative staff may be referencing out-of-date rules that lead to errors.
  4. If the healthcare provider confirms that the prior authorization is not required, they can submit the claim to the payer (which does not necessarily mean that the claim will be approved).
  5. On the other hand, if the healthcare provider confirms that the prior authorization is required, they will need to track down more specific information pertaining to each CPT code that is applicable to the prescribed treatment plan, as well as a number assigned by the payer that corresponds to the prior authorization request. These steps are typically done manually through a variety of phone calls, emails, and faxes.
  6. Without outsourced prior authorization services, the responsibility falls on the provider to continue this process and follow-up with the insurance company until there is a resolution to the request, whether that is an approval, redirection, or denial. This part of the process often leads to significant wasted time and effort due to it being unstructured and improvised.

How do outsourced prior authorization services with AuthNet work?

Clinicians can save both time and money on their prior authorization processes by outsourcing their prior authorization services to a team of specialists, such as the ones at AuthNet, who will take care of this entire process. All the healthcare provider needs to do is enter the appropriate demographics, diagnosis, and CPT codes into our secure portal, which will then prompt our team to start the process. Our experienced prior authorization insurance specialists manage this entire process from start to finish including follow-ups and appeals, so that healthcare providers can use their time more efficiently.

Have further questions regarding prior authorization services with AuthNet? Give us a call today!