The Complete Prior Authorization Cheat Sheet for Healthcare Teams

Prior authorization can be a major hurdle for healthcare teams, but it doesn't have to be. With the right knowledge, you can streamline the process and get patients the care they need.

The average prior authorization request takes 28 days to process, which is a significant delay for patients who need timely treatment. This can lead to frustration and dissatisfaction with the care they receive.

Prior authorization requirements vary by payer, but understanding the specific requirements for each can help you navigate the process more efficiently. For example, some payers require prior authorization for certain medications, while others may require it for specific procedures.

By staying organized and up-to-date on prior authorization requirements, you can reduce delays and improve patient outcomes.

Prior authorization is a process used by healthcare insurance companies to verify if certain medications, procedures, and tests prescribed by a healthcare provider are needed for the patient.

Payers often believe that less expensive treatment is sufficient, which is why they may advise patients to lower-cost sites of care or physicians.

In medication, pharmacy benefit managers (PHMs) should choose a less expensive drug before moving toward an expensive option.

The decision to reject or approve a particular process depends on the payer, and your reimbursement is completely dependent on their decision before providing the treatment.

The prior authorization process typically begins with the healthcare provider identifying the need for a service or medication that requires prior authorization. This involves determining the patient's need for a procedure, medication, or equipment that requires authorization.

The process usually involves submitting an authorization request to the insurance company, which may involve filling out a specific form and providing detailed information about the patient's medical condition and the planned treatment.

The insurance company reviews the request, which may involve their own medical experts, and may approve, deny, or ask for additional information.

The insurance company communicates their decision to the healthcare provider and the patient.

Here are the key steps in the prior authorization process:

Direct data entry (DDE) in the ProviderOne portal is a feature that allows providers to submit authorization requests directly into the system, including attaching records, color photos, and x-rays.

One common challenge in the prior authorization process is incomplete or inaccurate information, which can lead to delays and denials.

This can be avoided by ensuring that all required documentation is submitted upfront, as seen in the example of submitting a comprehensive treatment plan.

Incomplete or inaccurate information can cause delays and denials, so it's essential to double-check all submissions to avoid this common pitfall.

Delay of care is a significant challenge with prior authorizations, cited by 35% of respondents in a recent poll.

Administrative burden is another major pain point, with 32% of respondents struggling with it.

High-price drugs or services often require prior authorization, which can lead to delays in care.

Payers may reject non-emergency tests if they're not authorized, even if the test is medically necessary.

Administrative staff mistakes, such as clerical errors or misspellings, can result in denied prior authorization requests.

Inadequate information when submitting a prior authorization request can also lead to authorization denials.

Payers may require patients to try less expensive treatments before approving more expensive ones, which can cause delays in care if not followed.

Here are some common pain points with prior authorizations, categorized by their frequency:

Burnout is a state of emotional, mental, and physical exhaustion caused by prolonged stress, often leading to decreased productivity and performance.

Chronic stress can be a major contributor to burnout, as it can lead to feelings of hopelessness and detachment from work.

Self-care is essential in preventing burnout, including activities that promote relaxation and stress relief such as meditation and exercise.

Time management is critical in maintaining a healthy work-life balance, allowing individuals to prioritize tasks and avoid overcommitting.

Burnout can have severe consequences on mental and physical health, including increased risk of anxiety and depression.

Documentation is key to a smooth prior authorization process. You'll want to submit supporting documentation to an existing authorization, which can be done using a specific cover sheet.

For general PA requests, use the Pharmacy Information Authorization (HCA 13-835A) form as the first page followed by supporting documentation. This is the standard procedure when HCA didn't fax a specific form.

If supporting documentation was requested by HCA on a drug or drug class specific form, fax the form as the first page followed by the supporting documentation. This is an important detail to keep in mind when submitting additional information.

Here are three key tips to keep in mind when documenting the prior authorization process:

To speed up the prior authorization process, designate prior authorization responsibilities to the same staff member(s) to ensure consistency and efficiency. This can help reduce the time spent on prior authorizations.

Create a master list of procedures that require authorizations to streamline the process and ensure that all necessary steps are taken. This list can be updated regularly to reflect changes in procedures or payer requirements.

The prior authorization process typically begins with the healthcare provider identifying the need for a service or medication that requires prior authorization. From there, the key steps often include submission of the request, review by the insurance company, and communication of the decision.

To minimize prior authorization delays, find low-priced alternative drugs that are equally effective for patients, which can skip the prior authorization process altogether. This can help reduce the time and resources spent on prior authorizations.

Here are some tips to optimize the prior authorization process:

By implementing these strategies, healthcare providers can optimize the prior authorization process and reduce the time and resources spent on prior authorizations.

Following up on prior authorizations can be a challenge, but it's crucial to ensure timely approval and patient care. Sometimes, payors don't send notifications in real-time, so it's essential to follow up.

Create a follow-up plan with your staff to stay on top of prior authorizations. Follow up with payors every 48-72 hours to ensure you're informed of the status. This proactive approach can alleviate delays and keep patient care on track.

Don't rely on payors to communicate approved authorizations in a timely manner. Familiarize yourself with payor requirements, as each one has its own nuances and variances by service type.

Following up on prior authorizations is crucial to avoid delays in patient care. Sometimes, payors don't send notifications in real-time, so it's essential to follow up.

Create a follow-up plan with your staff to ensure timely communication. Don't rely on payors to inform you of approved authorizations.

Following up every 48-72 hours can help alleviate some of the delays. This regular check-in can also help you stay on top of payor requirements.

Familiarize yourself with payor requirements, as they vary by type of service rendered. Every payor has different needs, making it challenging to stay up-to-date.

Don't forget to follow up on prior authorizations to ensure timely approval. Following up is key to providing quality patient care.

Maintaining a list of payor contacts can save you time and hassle. Create a quick reference guide of your payor contacts to help you process prior authorizations more quickly.

Having a centralized list of contact information for your payors can be a game-changer. You'll be able to quickly look up the necessary information and get in touch with the right person.

Here are some key contacts to include in your reference guide:

Having the prior authorization forms for each payor on hand can also be helpful. For example, Cigna's prior authorization form is readily available, while Humana's form should be faxed to (877) 486-2621 after completion.

Prior authorization requirements can be a challenge to navigate, but understanding the basics can make a big difference. Every payor has different requirements, and it's essential to familiarize yourself with them.

To start, you should check if a treatment or service requires prior authorization. This can be done by using provider billing guides and fee schedules to review policy. Make sure to check the National Correct Coding Initiative (NCCI) guidelines prior to submission, as HCA's authorization services do not consider them.

The prior authorization process is designed to ensure patients receive safe and medically necessary treatment. According to America's Health Insurance Plans (AHIP), this process prevents duplicate and unnecessary tests and treatments.

Here are some key steps to keep in mind:

Health insurers require prior authorization to ensure patients receive safe and medically necessary treatments. They check if the prescribed drugs or services are truly needed based on the patient's condition.

Payers review whether the recommended treatment is necessary for the current situation, and not just a general requirement for the medical problem.

If a cheaper alternative is available, the doctor must explain why the more expensive option was suggested. This helps keep healthcare costs in check.

Duplicate services are also a concern, especially when multiple specialists are involved in treating a single patient. If a specialist has already prescribed a test or treatment, the payer might not authorize a repeat unless the doctor provides a strong reason.

Here are some common reasons payers might deny prior authorization:

By understanding these requirements, patients and healthcare providers can work together to ensure quality care and avoid unnecessary delays or denials.

Determine Requirements is a crucial step in the prior authorization process. This involves reviewing policy and checking if a code or service requires prior authorization. You can use provider billing guides and fee schedules to find out the requirements.

Every payor has different requirements, so it's essential to familiarize yourself with each payor's rules. Not to mention, there are variances by type of service rendered, making it challenging to stay up-to-date.

To manage the nuances for each payor, here are some easy tips to help you:

The EPA number must be used when the provider bills the agency, and upon request, a provider must provide documentation to the agency showing how the client's condition meets all the criteria for EPA. A written request for prior authorization is required when a situation does not meet all the EPA criteria.

Maintaining a list of quick ways to contact your payors will help you process prior authorizations more quickly. Create a quick reference guide of your payor contacts to save time and effort.

Prior authorizations are required to ensure the patient is receiving a safe treatment that is medically necessary and appropriate. This process helps prevent duplicate and unnecessary tests and treatments while ensuring the patient is receiving the proper care for their condition.