How to Enhance Your Prior Authorization Strategy

Prior authorization is an eligibility verification process, which requires health care providers to obtain approval from a health insurance provider before a specific service is delivered to the patient. Providers need to improve their prior authorization strategies to reduce cases of claims denials and optimize their revenue collection. Read along to learn more!


Eligibility and prior authorization challenges are fairly common in medical practice, and if you are managing a medical practice, you would have had your fair share. Let’s take a look at what prior authorization is about before exploring the tactics, tricks, and best practices for tackling it.


Prior authorization: what does it mean?


Prior authorization is an eligibility verification process, which requires health care providers to obtain approval from a health insurance provider before a specific service is delivered to the patient. For a service that requires prior authorization, if you don’t get the prior approval before rendering the service, the service will not qualify for payment. Thus, the process enables practices to reduce claims denials and optimize cash flow. If your prior authorization processes are poor, you will have more denials and a decrease in revenue.


Priority should be on front office operations


Your front office team is your first line of attack in preventing denied claims. Thus, eligibility verification should be more than merely collecting and recording the right insurance information, which is only one of the necessary steps in enhancing the eligibility process. Your administrative team should go further to get the details of the plan: whether the plan will cover the scheduled procedure, the plan requires a referral for service, the patient has met the plan deductible, and at what percentage.


Since it is important to go deeper and get the details, you need to train your administrative professionals to know what to look for. Also, your team must have a policy of taking an in-depth look into eligibility verification before rendering service, as well as whenever a claim is denied. Note that if your eligibility verification process is poor, you will lose money!


Your strategy should be clear


You should already know the following before the patient arrives:

  • The patient’s insurance plan
  • Policy coverage for the service you want to render to the patient
  • How much of the cost is the responsibility of the patient
  • How much of the cost is the responsibility of the insurance firm
  • Any requirements needed by the insurance firm to get the claim approved and paid

Responsibility of the patient


The patient has a responsibility to understand the details of their policy, as they are responsible for any expenses incurred, including those resulting from a denied claim. In practice though, most health care providers often verify coverage and file claims on the patient’s behalf. But taking ownership of the process can result in unpaid claims and lost revenue. It is, therefore, important to clearly communicate to your patient about their responsibility for the cost of treatment.


Identify the payer


Apart from policy coverage, specialist providers should know the details of the payer guidelines. For instance, an insurance firm may not always approve a skin lesion’s removal if the treatment falls outside a specific diagnosis code, or if the service falls under a certain scope of care. In this case, the health care provider should know in advance that the insurance would not authorize payment for the service and thus should have a way to identify the patient as the payer.


Having a strategy for identifying the patient as the payer is very important if a practice frequently deals with out-of-network plans. Whatever the case, the front office team should always make sure to collect from the right payer, whether that be an insurance or the patient, if you want to make any money from out-of-network services.


Improve your pre-authorization approval process


Making sure you get pre-authorization from every payer who requires it is one simple strategy to ensure you’re collecting every due to the services you render. So, you have to improve your eligibility processes, by doing the work ahead of time to prevent claims denials.


Getting pre-authorization before rendering service is essential to driving revenue because more often than not, claims denials due to a lack of pre-authorization don’t ever get paid at all. Moreover, if the patient is asked to pay the due amount, they are unlikely to make the full remittance. Thus, you must have a clear pre-authorization strategy in place and make sure your administrative team fully implements it; if not, you risk leaving far too much money on the table.


To speed up your prior authorization process, reach out to your account representative at WCH; they can aid your team and advice you appropriately.

Know the deductibles and benefit details


While you make it a priority to work closely with your patients’ insurance providers and always get approvals where required, you should also make it a point to check deductibles and benefit details.


Things you must check include

  • Whether there are deductibles and if it has been met
  • Specific coverage rules
  • If the service is covered
  • How the plan handles that service


When you verify this information ahead of time, you’re setting a standard with your patients so they know what to expect. While this may seem tedious, your effort to verify the eligibility status for every service, no matter the value, will improve your practice’s reimbursement rates across the board.


Have eligibility checklists


To enhance your practice’s eligibility process, each time you determine a patient’s eligibility status, ask yourself the following questions:

  • Does this patient require prior authorization?
  • Have I obtained the necessary approval?
  • Has the patient’s deductible limit been reached?
  • Have I checked the specific specialty coverage rules?


One more thing, consider whether your staff is knowledgeable enough to handle prior authorization matters. To ensure that obtaining prior authorization becomes a core focus for your practice, you may have to train your staff in that regard.


Ensuring excellence in your eligibility tactics will improve your practice’s prior authorization processes. Therefore, it is necessary to develop a growth mindset and a plan of action for eligibility procedures while ensuring your front office staff understands the key role they play in this endeavor. This way, your revenue collection efforts will start yielding good results.