Request Prior Authorization

Once you identify clients that can have services paid for by a third-party, it's important to know that most plans also require prior authorization for services. Prior authorization is the process of obtaining approval of coverage for a service or medication with a specific provider and network.

Since most third-party payers now require you to get authorization before you deliver services, it is common for a client's bill to be based on the treatment and services that the payer allows.

But what information do you need to obtain authorization? Information requirements vary for each payer. Some companies will authorize an initial course of four to six outpatient sessions with minimal information. Others may want a full bio-psycho-social evaluation and diagnosis before authorization. Find out by talking to the provider relations service representative for the third-party payer, and then create a checklist so that your clinical or intake staff are guaranteed to collect the information needed for authorization. Frequently, the clinical team must actually see the prior authorization for the inpatient stay. For outpatient treatment, prior authorization may be completed prior to the first session. Always check the third-party payer's website for guidelines and expectations for the services provided. And remember, using their terminology will assist in getting services authorized.

Questions:

Does your agency currently have a process for obtaining prior authorization? If so, what is the most difficult or time-consuming part of the process?

Do your clinicians prefer tailoring a treatment plan around services allowed by payers? Or do they prefer creating their own treatment plans regardless of prior authorization guidelines? If they prefer creating their own, how do you get services without prior authorization paid for?

Verifying Patient Insurance Coverage

Many treatment agencies are realizing the benefits of working with third-party payers. The collected fees can stabilize income flow, making it easier to provide charity care to a larger population. But even more agencies struggle with this process.

What happens when a client with insurance comes to your agency? Since you probably already gather information from clients at first contact, you can add another question to the process: Do you have insurance? You should ask the next client that says "yes" to bring their insurance card to their first appointment.

The first step of efficient billing is to learn everything you can about that client's coverage. Check the back of the patient's insurance card for contact information. You'll also need to know:

. Primary care physician information

. Total benefits covered

. Calendar year and lifetime max status

. Deductible: any met, and if yes, how much?

. Co-pay for all levels of care

. Claims address

. Certification (pre-authorization) phone number

. Lifetime maximum amount met

. Policy termination date

. Effective date

. Authorizations required

. Name of person you spoke with

These are simple, yet important, first steps in starting a third-party collection system. Does your agency collect from third-party payers? Do you gather all of the information listed above before or during a client's first appointment? Is there any reason why you cannot make this part of your agencies intake process? Please leave your comments, questions and stories below...