Pursue Optimal Efficiency Strategies 3-4

Use six key workflow strategies to improve your bottom line.

Strategy No. 3:
Seek Prior Authorization

This is critical because failure to obtain proper authorization can have a drastic affect on practice income. Insurers will not pay for procedures if they correct prior authorization is not received, and most contracts restrict practices from billing the patient in these situations.

Although neccessary, keeping track of prior authorization policies is challenging. Each health plan has its own set of requirements, which can change frequently. Some Medicaid payers, for instance, request one "blanket" referral authorization before patients see certain specialists; the specialist is not required to obtain prior authorization for every procedure. Other plans are much more restrictive, approving prior authorization for specified procedures only when certain criteria and diagnoses are met.

Here are three actions you can take to help navigate the prior authorization process:

    1.  Designate someone to oversee all authorizations.
         This allows a particular individual to become knowledgeable about each payer's unique
          requirements. This person should track the authorization allowed and used for procedure codes
         and visits, and be diligent about obtaining authorizations. By gaining a more thorough underst-
         anding of payer policies, this person can better fight inappropriate authorizations denials.

    2.  Open the line of communication. Two-way communication between physicians and
         authorization staff is essential. Providers should document completely and tell staff why a
         patient is being seen, so staff can inform providers about the treatment options the patient's
         payer will accept. Providers can them make treatment decisions based on all relevant knowledge.

    3.  Leverage technology. It can be helpful to develop a spreadsheet listing the guidelines for payer
         authorizations, including which specific codes require authorization. The spreadsheet should
         explain what justifies medical necessity for each procedure, according to each payer. Using
         this tool, you can quickly decide when to submit an authorization request. Note: Some payers
         publish their pre-authorization guidelines on their website, while others require you to call and
         request these.

Strategy No.4:
Ensure Timely Charge Entry

Lagging charge entry can delay payment and hinder accounts receivable (A/R) negatively affecting your practice's bottom line. An important way to improve the timeliness of charge entry is to ensure coding staff has a solid understanding of ICD-9, ICD-10 (prior to October 2013), CPT, and HCPCS Level II codes, and modifiers. Hold meetings once or twice a month for coding staff to discuss coding- related issues and new developments to make sure everyone is up to speed on current requirements.

Educate physicians on importance of timely charge entry as well. Such education may involve explaining the consequences of delayed charge entry, and how those consequences affect physicians directly.

Once coded, claims may be run through claim scrubbers, clearinghouses applications, or other tools that verify accuracy. By ensuring a clean claim upfront, your practice can avoid costly delays and reimbursement headaches from denials down the road.