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!

Is your patient getting the test they need at the right time?

The doctor orders an MRI, CT, PET scan or nuclear medicine scan for their patient. The paperwork is given to medical office staff to get prior authorization, aka precertification from the health insurance company. You call in and give the medical insurance information, study requested, CPT code, diagnosis, demographics of the patient, site and medical office. Then you are transferred to a clinical reviewer, usually a nurse. Questions are asked about the patient's medical history, signs and symptoms and physical exam findings just to name a few. This is where most medical staff have problems. The answers to these questions will determine if the test is needed. If it is not immediately approved, the case is sent for review to a medical director, who is a physician for the health insurance company. This can take up to two business days if it is not medically urgent. If the medical director asks for additional information, add about another two days for the medical office to respond. Add about another two days for the medical director to make a final determination. In the meantime, you are waiting for an answer. The patient is waiting to have their test done. This is frustrating for everyone involved. It is my experience that 1 out of 3 medical office staff are unable to provide complete clinical. This results in an automatic medical review.
This is where I can help you. No matter what experience you have had with prior authorization, you can benefit from my educational program. I can teach you how to be a "pro" at providing clinical, understanding the study being requested and give many, many tips on how to avoid the red tape and help you to be more efficient in this process. Contact me today to talk about how I can help you right now.