Prior Authorization

Why Outsource Your Prior Authorizations to InlandRCM?

Eligibility Verification

Ensuring that the patient’s insurance coverage is active and valid for the requested procedure or treatment and confirming the specific benefits and coverage limits.

Prior Authorization Request

Submitting formal requests to insurance providers for approval of medical services such as surgeries, diagnostic tests, and treatments that require prior authorization. This step typically involves providing detailed medical information, including diagnosis codes and treatment plans.

Timely Follow-up

Tracking and following up on submitted authorization requests to ensure they are processed within the required timeframe. This helps prevent delays in patient care.

Insurance Notification

Notifying insurance providers of admissions, discharges, and significant changes in patient care (for example, surgery schedules) as required by insurance contracts. This ensures compliance with payer rules and prevents denial of claims.

Patient Communication

Keeping patients informed about the status of their prior authorization, helping them understand any potential delays, coverage issues, or out-of-pocket costs.

Denial Management

Handling denials or requests for additional information from insurance providers. This may involve gathering more clinical documentation, re-submitting requests, or appealing denials to ensure coverage is approved.

Documentation and Recordkeeping

Maintaining accurate and detailed records of all communications, submitted documents, and authorization approvals. This is crucial for both compliance and potential audits.

Real-time Integration with Hospital Systems

Ensuring that the prior authorization process is integrated with the hospital's electronic health record (EHR) system and billing software to streamline the process and reduce manual errors.

Regulatory Compliance

Ensuring that all processes comply with healthcare regulations, such as HIPAA, and with specific payer policies and guidelines.

Benefits of Prior Authorization Managment

  • By ensuring that all necessary approvals are obtained before services are provided, a good prior authorization process reduces the likelihood of claim denials. Denied claims can be costly to rework and appeal, and often lead to delayed or lost revenue.

  • Faster approvals mean that claims can be submitted promptly, resulting in quicker reimbursements from payers. This improves the overall cash flow of the hospital, ensuring that funds are available to cover operating costs and investments in patient care.

  • A streamlined and efficient prior authorization service minimizes the time and effort spent by staff on manual paperwork, follow-ups, and correcting denials. This leads to lower administrative expenses and allows staff to focus on other revenue-generating activities.

  • If prior authorization is not obtained, hospitals may provide services that are later not covered by insurance, resulting in uncompensated care. A good process ensures that services provided are eligible for reimbursement, reducing financial losses.

  • When prior authorizations are handled smoothly, patients are less likely to experience delays or financial surprises, improving their satisfaction with the care they receive. Satisfied patients are more likely to pay their portion of the bill, improving revenue collections.

  • By reducing delays in the authorization process, hospitals can schedule procedures more efficiently, ensuring that medical resources such as operating rooms and staff are utilized effectively. This maximizes revenue opportunities.

Need a Custom Solution?

If you're looking to streamline your billing processes and improve your revenue cycle, our Central Billing Office service may be just what you need. Contact us today to learn more about how we can help your business succeed, or to speak with our team about a custom solution tailored to your unique needs.