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?
I would be interested in learning what staff or personnel agencies have selected to obtain their prior authorizations and why. For example: front desk staff, clinician, billing.
ReplyDeletePosted By jjpulvermach
Question1 Reply-Yes, we get prior authorizations. Difficult and time consuming part is the deadlines set by insurance companies. They typically want more clinical information than we have at the time of admission.
ReplyDeleteOur clinicians prefer to not be bothered by insurance company expectations. They leave this to me as the insurance guy to make it right. I study the prior authorization guidelines and address them with the clinician and the patient to ensure that we present the most acurrate picture of how patient meets preauthorization guidelines.
Posted By ecarson@decision-point.org
Unfortunately, most of our clinicians focus on the clinical part-not the financial part. They create their own treatment plans. Our services are usually authorized during or after the service is provided. We have a billing specialist that does financial intakes which helps generate accurate info.
ReplyDeletePosted By yvonnes@circstark.org