Prior Authorization, The Ultimate Tool To Successful RCMPrior Authorization, The Ultimate Tool To Successful RCM

Taking the audience through the passage called prior authorization, the concept, the origin, the modus operandi, the modern modifications along with interesting tit bits about the recent developments in that regard. An important slice of statement regarding a very important aspect of revenue cycle management.    

What is prior authorization?

Prior Authorization is the basic step that is taken to ensure a successful compensation of medical expenses incurred by a provider of medical goods and/or services. The cycle of medical treatment and compensation starts with the patient visiting the doctor and the doctor forwarding the treatment portfolio along with the claims for the expenses incurred to the insurance payer for reimbursements. These expenses have to be confirmed by the payer first as provided for in the policy to ensure their safe recovery in the longest run. The protocol followed for this confirmation is called prior authorization.              

The beginning of prior authorization

At first prior authorization would be practiced by the clerical offices of the respective medical service providers. However due to excessive work load and lack of proper professional experience the process and practice of prior authorization would often remain incomplete leading to accumulation of work, issues of non-payment, delayed results, pre-occupation with financial fuss causing lesser time for the patient’s wellness and on an average a convoluted economic crisis in the health industry. In order to avoid the imbroglio, specialized agencies with academic degrees for prior authorization have taken over to provide best possible solutions to pre auth problems.        

The process

A generic process of prior authorization goes as under

Authorization Initiation

Calling up the insurance company to know their request filing protocol, documentation requirements and turnaround time
Collecting the medical papers as required from the payer
Submitting the request as per the protocol
Tracking the receipt of the same

Authorization Follow Up 

Calling up the insurance company to know the status of the pre auth request and also furnishing the required documents as asked additionally by the payer company.

Authorization updating

Uploading the final statement of the request as per the approval or the denial in the provider’s system along with the required service information like the start and end date if the bucket etc.   

 The present situation

With the start of the new millennium we have seen a proliferation of specialized agencies practicing end to end as well as standalone service of prior authorization. Increasing digitalization has paved the way web based functioning format for less time consuming prior auth practice which is also client friendly and accurate.  Academic courses are abounding in literary disciplines regarding various streams of revenue cycle management, prior authorization being a major course curriculum under which. An increasing number of population is being driven towards taking up medical billing and its various facets as their main stream career leading to industrial betterment. 


Trivia about prior authorization

The American medicine industry has initiated prior authorization be practiced mandatorily in its electronic form. A number of states in America have adopted this already or are considering the regulations regarding the same to expand the scope of automated Prior Authorization. It means developing an online portal to receiving and executing the requirements of prior auth requests and regulations. The number of complying states and the users are expected to rise sharply in future.

by Willam Smith
References and Bibliography

Willam Smith is an experienced prior authorization practitioner who writes for the internet audience form his vast bouquet of experiences for a better theoretical understanding of the subject.

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