Getting bogged down by authorization denials? You’re not alone. Here, we explore common roadblocks and effective strategies to keep your revenue flowing smoothly.
Challenge: Drowning in Last-Minute Authorizations
Solution: Divide and Conquer with a Multi-Team Approach
Separate teams can tackle present and future authorizations. The “Today” team verifies benefits and identifies authorization needs for upcoming appointments. The “Future” team focuses on authorizations for appointments beyond 72 hours. This team can be further segmented by volume (e.g., 2-7 days vs. 7+ days out) to prioritize urgency. This allows focused attention on high-priority cases while ensuring timely authorization acquisition.
Challenge: Physician Offices Dropping the Ball on Authorizations
Solution: Partnering for Efficiency
Collaboration with non-employed physicians can be tricky due to limited integration, accountability, and prioritization on their end. Since referring physicians are reimbursed regardless of authorization, the responsibility often falls on hospitals. To address this, consider a formal agreement: the hospital obtains authorizations in exchange for the physician providing all necessary clinical information. This streamlines the process for both parties. Hospitals gain control over authorization and ensure reimbursement, while physicians are relieved of this time-consuming task. This method is ideal for high-cost procedures like MRIs, CT scans, and ultrasounds.
Challenge: Incomplete Documentation Leading to Denials
Solution: Documentation is Key
Empower your staff to meticulously document authorization details, including:
- Authorization number/code
- Authorized services and level of care
- Any limitations on scope or duration
- Date and time of authorization
- Method of obtaining authorization (phone, electronic)
- Name of the insurance representative
- Documentation of unresponsive payers aids in appealing denials and underpayments.
Additionally, implementing a policy where nurses verify procedure codes before closing charts can prevent rework. If a code changes, the account automatically returns to the authorization team, allowing for proactive updates and preventing denials.
Regular communication is crucial. Foster collaboration between Pre-Access Authorization/Admission Support and Utilization Review teams through frequent meetings. This strengthens communication, teamwork, and overall process efficiency.
Challenge: Keeping Pace with Ever-Changing Payer Requirements
Solution: Empower Your Staff as Insurance Experts
Designate a team of insurance specialists to liaise with Contract Management. These specialists can stay updated on payer policies, create staff resources (like payer requirement matrices), and publish internal newsletters with relevant information and tips for interacting with specific payers. Ensure this information is readily accessible to all departments involved in the authorization process.
By implementing these strategies, you can streamline authorizations, minimize denials, and keep your revenue cycle healthy. We’d love to hear your experiences! Share your authorization-related challenges and solutions with us via the form below.
Minimize Authorization Denials with These Top Tips
Authorization denials can be frustrating, but there are steps you can take to minimize them. Here are some key strategies:
Before Submitting:
- Verify Patient Eligibility: Double-check that the patient’s insurance is active and covers the requested service.
- Confirm Need for Authorization: Not all services require prior authorization. Check with the insurer to avoid unnecessary requests.
- Use the Right Tools: Consider using software to streamline the process and reduce errors.
During Submission:
- Accuracy is Key: Ensure all information on the request is accurate, including patient demographics, diagnosis codes, and procedure codes.
- Clear and Compelling Begründung (Justification): Clearly explain why the service is medically necessary. Back it up with evidence-based guidelines if possible.
- Follow Payer Guidelines: Each insurer has specific requirements. Pay close attention to their instructions for submitting requests.
