Prior Authorization Denials and How to Avoid Them
Healthcare providers struggle to keep prior authorization denials as low as possible. This is because PA denials are inevitable to a certain extent. Most avoidable denials are a result of silly admin errors. But besides these avoidable errors, some denials defy logic.
In case of logic-defying denials, it is best to follow the standard operating procedure, even if it takes time. But for this blog, we will discuss how to avoid pre authorization denials and the key strategies to do so.
Pre authorization plays a pivotal role in securing timely approval for medical services. While it aims to regulate resource utilization and ensure cost-effectiveness, the process is extremely prone to denials, causing delays in patient care.
Why Avoid Prior Authorization Denials?
Prior authorization denials delay the delivery of necessary medical care. They also lead to administrative hassles and financial setbacks for patients and healthcare providers. The pre authorization process is a complicated mix of Utilization Management (UM) criteria and insurance coverage guidelines.
This complexity makes professional prior authorization services the best choice for HCPs to delegate their admin burden, instead of maintaining in-house operations.
Key strategies to avoid prior auth denials:
1) Thoroughly assess medical necessity:
- Scrutinize prescriptions with diagnostic imaging tests, durable medical equipment, and rehabilitation services to ensure they align with genuine medical necessity.
- Uncover and rectify any potential gaps in medical justifications that may lead to denials.
2) Prioritize cost-effectiveness:
- Emphasize cost-effective alternatives before resorting to pricier options in prescriptions, tests, or procedures.
- Be vigilant about the economic considerations associated with medical equipment and expensive prescription drugs.
3) Eliminate administrative errors:
- Tackle administrative mistakes in medical coding, billing, or form completion head-on to avoid unnecessary denials.
- Resubmit requests with accurate information, ensuring a smooth prior auth process.
4) Align with insurance coverage guidelines:
- Stay informed about the ever-evolving set of insurance coverage guidelines. For example, to get a UnitedHealthcare prior authorization or a Medicaid prior authorization, one should have a
sound knowledge of UHC and Medicaid pre authorization guidelines.
- Tailor pre authorization requests to align seamlessly with the specific policies of each insurer, preventing rejections based on misalignment.
Avoid Denials with Sunknowledge’s Prior Authorization Services:
Sunknowledge is a HIPAA-compliant healthcare revenue cycle management company. Since 2007, we have been helping healthcare providers across the US to reduce pre authorization denials cut down waiting times, and lower operational costs. Our certified PA specialists, equipped with operational experience and continuous training, guarantee precision and compliance with UM requirements.
For more information about PA best practices or to learn more about our prior authorization services, contact Sunknowledge.