The increased cases of cybercrime during the year 2018 – 2022 raised cybersecurity concerns. A shocking 93% increase in large breaches was reported to the Office for Civil Rights. This not only increased cybersecurity concerns but also disrupted the overall healthcare system. Back in 2022, under the governance of President Biden, the U.S. Department of Health and Human Services took notice of these cybercrimes, and in December 2023 a report was released with a special focus on a robust security system for healthcare practices and patients.
What is Prior Authorization?
Prior authorization is a process used by insurance companies to determine whether they will cover a specific medication or treatment. Before a patient can receive a prescription, the doctor must obtain approval from the insurer. If approved, the insurance firm provides an authorization number confirming coverage. This step helps ensure that the treatment is medically necessary according to the insurer’s guidelines.
Types of Prescriptions that Require Prior Authorization
Not all prescriptions require prior authorization, but several types often do. Common examples include:
These are high-cost drugs used to treat chronic (long lasting) diseases. These drugs are usually injected, however, can sometimes be consumed from mouth as well. The complex conditions include but are not limited to as cancer or multiple sclerosis.
Though all the drugs are being produced by different companies and have brand names. Some of them are known as patent drugs, these are the ones which is patented, means no other company can use this invention for a limited time period. If a generic version is available, insurers may require prior authorization for the brand-name alternative.
Some diagnostic procedures which involve testing, and surgical procedures which simply involve operation or surgery may also need approval before being performed.
The specific requirements can vary significantly between insurance plans, making it essential for healthcare providers to stay informed.
How Challenging Prior Authorization Can Be for Doctors
For many doctors, the prior authorization process can be challenging as it often involves the following:
The overall paperwork is a lengthy and tiresome process. Especially, if we talk about physicians, they are usually required to complete detailed forms and provide supporting documentation, which can be tedious and take time away from patient care.
Prior authorization takes time and the waiting period for approval can lead to delays. This interrupts or postpones the treatment which can have bad impacts on their medication and overall health.
Coping up with the policies and complexities of different insurance companies can be annoying for both doctors and patients. In some cases, this may affect the doctor-patient relationship as well.
Prior Authorization Benefits for Patients and Doctors
Despite the challenges, Prior Authorization can have its benefits for healthcare specialists. Some of these include:
Prior authorization costs less in a manner that the prescriptions are always double checked for if there is a more cost-effective option available than can do the job. In case, doctor / healthcare specialist proves that the prescribed medication is better in terms of results only then the expensive option can be authorized.
Once the suggested medication goes through the authorization process. It is checked closely if this is the correct medicine for the specific problem, is there is a better solution to this medication, or if the latest research goes against this. Moreover, they also check if you have already undergone a specific test previously (in case of a valid test) and your new doctor or healthcare specialist has mistakenly asked for the same test again.
Looking for a prior authorization specialist? Get a quote from HelloMDS now.
Better Results with More Focused Practice
As a healthcare provider, your primary focus is on your patients. However, managing the complications of prior authorization and the revenue cycle can be bothersome. This is where you may need a hand of a company that can take care of complete revenue cycle management process. By partnering with professionals who specialize in revenue cycle management, you can:
A dedicated team whose sole responsibility is to look after your prior authorization or any RCM related need can help expedite approvals and reduce delays significantly. This give your patients the experience they are looking for.
Removing the burden of complete revenue management, or just the part of it, allows you to focus more on your patient. Plus, swift approvals from the insurance companies play its own part in making the customer experience better. This expedited process increases revenue and help you expand your practice.
Conclusion
Prior authorization may involve some complexities but it also plays a crucial role in ensuring the best treatments at the best possible costs. Doctors can increase their revenue and decrease the extra load by selecting the best revenue cycle management companies in the USA.
