Are you aware how much time your practice spends obtaining prior authorizations for a patient’s care? Are you aware of the clinical knowledge one must know or have documentation for in order to obtain a prior authorization? I have a client that told me he had a nurse consistently sitting on hold with a particular insurance company for 30-60 minutes, up to four hours for one patient. As you can imagine a nurse’s time could be spent in ways tied closer to revenue generation.

In the revenue cycle – prior authorization is a key component IF required.  The key is VERIFYING BENEFITS to know whether a prior authorization is required.  If one is required, can the schedule accommodate the payers’ timelines for obtaining said authorizations? Most payers have an online option for submitting authorizations. Faxing in requests for authorization is becoming an antiquated method of request.

What happens when the request for authorization is denied or not completely covered? A recent story published in The Des Moines Register fatal flaws in the Iowa state funded Medicaid programs. Care was denied due to a gentleman because his caregiver/agency for home health care did not have the proper training. While the family struggled to find a solution, the gentleman ended up in the hospital and then could not be released because the proper level of care was not available for the time the he needed care. Imagine that individual being your child, spouse, or parent…what would you do…the reason for the disability was a car accident…would that individual be better off in a coffin?

Wake up legislators.  These are people – these are our children, our spouses, our parents…where do you want your loved ones to be?  Institutionalized or at home? As a financial consultant in healthcare, I guarantee it is CHEAPER for the payers and has better OUTCOMES for patients if they are allowed to stay home. Study after study after study has proven home based or community based environment contribute to less health expense and longer happier lives for disabled and chronically ill patients.

I am not advocating AGAINST Managed Care Organizations/privatized Medicaid, conversely, if executed correctly with a proper transition period – it should save both the state and federal governments a lot of money. However, there needs to be a focus on the patient not the dollars.

Getting back to prior authorizations and benefit verification – automation is key.  If you have the option of automated eligibility verification – DO IT. If you don’t – contact me…and we will make it happen.  There are many platforms now used to verify benefits prior to a patient’s arrival. EDUCATE your practitioners on procedures that MAY require prior authorization – have them schedule another appointment (more revenue for the practice). Train an individual with medical terminology/coding skills to be your prior authorization person. DO NOT waste the talent of your RNs on obtaining prior authorizations. In specialties – there should be a set of procedures each practitioner would do…diagnosis as to why…and additional information can always be gathered if needed.

Contact FinanSynergy, Katie Fergus, to review your current processes for eligibility verification, prior authorizations, and medical billing needs 515.635.5531 or katie@finansynergy.com