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Prior Authorization Requirements and Outsourcing to Specialists

Prior approval is required as part of the medical billing process. Specific requirements need to be met for prior authorizations to be processed. These include verifying insurance coverage, obtaining all necessary medical information, and ensuring that the correct billing codes are used.

Additionally, providers must be prepared to deal with any issues or delays that may arise during the authorization process. However, prior authorizations can be handled efficiently and effectively with the right tools and resources. Portiva’s prior authorization specialists can reduce this administrative burden for you and your staff.

Why are Prior Authorizations Necessary?

Medical prior authorization is necessary to ensure that medical bills are accurately processed, and medical procedures are covered by the patient’s health plan. Prior approval also ensures that patients receive the correct reimbursement from their health insurance plan. Medical prior authorization is usually requested from health insurers. Most insurance health plans require prior authorization before patients can receive specific procedures or medications.

If prior authorization is not obtained, the health insurance company will not reimburse any services rendered. Either the provider or the patient will be covering the entire cost of treatment or services not included in the patient’s health plans. Although prior authorizations enable health insurance companies to control expenses and prevent unforeseen patient costs, it has inadvertently taken a toll on the revenue of most healthcare practitioners.

The health insurance company may only approve prior authorization requests for a certain number of visits after receiving a clinician referral. The healthcare provider or their staff will need to submit updated information on those visits in cases where additional ones are needed. In addition, most prior authorizations have time limits on how long patients have to complete the number of visits permitted. This poses the additional burden of efficiently scheduling patients without compromising physician effectiveness and causing burnout.

Given the great necessity to obtain approval for prior authorizations, investing in software and people dedicated to handling this part of your practice would be the best practice. Integrated software can do wonders in cutting time spent in manually processing prior authorizations. In addition, outsourcing this work to a reputable company like Portiva would increase your time spent with patients and ensure constant revenue.

Prior Authorization Process

The process of prior authorization is costly and time-consuming. The AMA 2017 study revealed that 84% of the participants conveyed a high or extremely high burden of prior authorization on physicians and medical staff. Physicians spending around 20 hours per week interacting with insurers means over $20 billion in annual costs for the U.S. healthcare system.

  1. The process starts with the physician ordering a procedure for a patient.
  2. The front office staff then enters the physician order in the appropriate system for verification and eligibility.
  3. The staff then determines the prior authorization requirements, which constantly change with each health insurance company’s rules. This part of the process alone could cause delays that hinder patient care.
  4. The staff may need to obtain forms specific to certain plans, which might require long holding time with the insurers. It would be convenient if such forms were available for download via their website.
  5. The staff then submits the correct CPT code, the prior authorization request form, and other supporting documents to the health insurance company.
  6. The request for prior authorization will either be approved or denied, usually within five to ten business days. So, it is vital to monitor this part for timely review requests of the decision if necessary.
  7. The staff may request a review of choice if the prior authorization is denied. The physician may also recommend an alternative course of treatment in some cases.

If any of these actions are skipped correctly, or if there are any issues with the authorization process, it can lead to delays in reimbursed and even denied claims. With Portiva’s prior authorization specialists, however, you can minimize these administrative headaches and focus on providing quality patient care.

How can Providers Prepare for Prior Authorizations?

Ensure Data Entry Accuracy And Completeness

Prior authorizations usually take a lot of time due to incomplete or incorrect information submitted to the insurance health plan. This may lead to a denial and numerous hours of rework for the provider and the staff. Any prior authorization form errors may cause the system to flag it for denial.

Having a Portiva specialist handle your prior authorization reduces denied requests significantly, leading to higher patient adherence to treatment. We ensure that healthcare providers are compensated for the services rendered by carefully ensuring that the correct data is submitted. A wrong digit in the health ID number or a wrong middle initial letter could be the difference between an approved or denied request.


Save Time By Outsourcing To Specialists.

Errors can arise due to the complexity of the prior authorization process, which often involves many manual steps. Health companies often require patient information, provider data, specific service requests, and medical scenarios. Any missing details can trigger a denial, and once that status has been given, it is cumbersome to reverse.

Portiva’s specialists are trained to handle various complex forms and are often familiar with the different requirements of various insurers. Having a prior authorization specialist combined with streamlined, integrated software, you can increase your approvals while reducing wait time. Studies have shown that prompt care improves patient adherence to treatment health plans.

Monitoring Reviews And Ensuring Open Communication

Even with the steps taken to ensure accurate data, medical reviews associated with prior authorization can be lengthy. This can delay c, leading to uncertainty and frustration for providers and patients. This can lead to the abandonment of care and leave the provider to shoulder massive costs.

With a prior authorization specialist, you can be assured that communication lines are always open between physicians, patients, and insurers, leading to better outcomes. It is highly beneficial that patients know how much work is placed in getting prior authorizations which encourages adherence to the health plan. Providers are also assured that they are compensated at the end of the day for any services rendered to the clients.

Balance Automation And Manual Work 

Automating the prior authorization process reduces the likelihood of errors. The earlier this is done in the revenue cycle, the better chances of avoiding clerical mistakes. Automation also reduces the amount of manual work wasted on tedious tasks and preserves energy for double-checking data to ensure accuracy. Digitizing most of the process cuts time significantly, leading to accelerated patient care.

Portiva’s prior authorization specialists ensure that every automated part works for your benefit rather than cause further delays. Systems still need the watchful eye of humans to ensure end-to-end accuracy and data quality. Great systems are managed by a great team of specialists to promote a work-life balance vital to any medical practice.

In Summary

Prior authorizations are necessary but can be time-consuming and frustrating if done incorrectly. With the help of a specialist, Prior Authorizations can be processed quickly and efficiently, leading to better patient care. Automating the process can reduce errors, but human oversight is still necessary for accuracy.

If you’re interested in learning more about prior authorizations or need assistance managing this part of your medical billing workflow, we can help. Our experienced team of prior authorization specialists can help you navigate the prior authorization process and ensure that your claims are processed quickly and accurately. So why wait? To discover more about how we can assist with prior authorizations, contact us right away at!