Sunday, January 17, 2010

Health Care Reform and Effects on Prior Authorization

There will be some type of healthcare reform. At this time, no one is quite sure exactly how it will pan out. But there is one thing that will not change. That is prior authorization for advanced imaging. No matter what, medical providers will still have to justify why the test is needed.

Health care is cost driven. In order to control the costs of advanced imaging, the need for the test must be documented. The prior authorization process itself may change. The American College of Radiology is pushing to cut out the middle man (radiology benefit managers). They are recommending Electronic Decision Support(EDS), an online software program that determines appropriateness. This program will allow medical providers to input the clinical information which will automatically rate the appropriateness of the test being requested. It may also suggest an alternative test. If the medical provider does not accept the recommended test, they will be required to have a peer-to-peer discussion or talk with an onsite radiologist.

What will not change in this process is the fact that medical staff must still input the correct information. Even one small error can send a case for further medical review or if using the EDS system, spit out an inappropriate rating, causing delay.That is where my training program can help. I can teach medical office staff how to provide accurate clinical, avoid the most common mistakes and make the most of their time doing prior authorizations. Contact me for a free consultation on how I can help you today!

3 comments:

  1. I may also suggest an alternative test. If the medical provider does not accept the recommended test, they will be required to have a peer-to-peer discussion or talk with an onsite radiologist.

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  2. Hi. As a nurse I found it very frustrating to go through the pre-cert process. For non clinical staffer delegated to call in for approval is even more likely they can't get approval. It seems the system is almost set up to fail. Companies who are "middle men" like care core are a nightmare to deal with. Do you foresee this middle man situation changing? Good Blog by the way!

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  3. Thank you for your comments. So glad you like the blog! I wanted to address your question properly so I am dedicating a new post to talk about those "middle men". Because I know there are a lot of medical personnel out there asking the same question.

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