Handling prior authorization related denials

If you find out that a procedure requires prior authorization by the patient’s plan, immediately move the appointment to an “appointments at risk” bucket.

Categorized as Operations Tagged

When your eligibility team is checking for a patient’s eligibility for the specific procedure proposed by the provider, they will also find out whether this service/procedure requires prior authorization or not.

Give yourself adequate time to get the prior authorizations done. Prior authorization does take time and the payers do not always respond on your schedule. If you find out that a procedure requires prior authorization by the patient’s plan, immediately move the appointment to a “appointments at risk” bucket.

As described above, you need to call those patients and give them the options discussed above. In all probability you are going to get the prior authorization if you do your job properly so the patient would just need to reschedule their appointment to after you obtain the prior authorization / pre-certification.

The workflow you are using here (or modifying) is that the billing department analyzes the denials, forms buckets, then trains / informs the front desk to make corrections upstream. This strategy allows you to reduce such denials moving forward.