MGMA Stat from Sept 2018 shows an 86% increase in required prior authorizations.

To keep pace with changes to healthcare reimbursement, hospitals and healthcare organizations need to reduce inefficiency in their revenue cycle management.

One significant cause from revenue loss is claim denials due to lack of prior authorizations. You cannot work backwards to get retro-authorizations for most insurance companies.

Therefore, no prior authorization = no payment.

Take a deeper look…

How do your staff handle the ever-increasing demand for prior authorizations?

When prior authorizations for a procedure are managed, it’s often the front-desk staff or a nurse who fills out the orders and they are not often familiar with the medical necessity requirements set by each individual payer.

Also, doctors often think they know the payers’ medical necessity policies, but are not coding to the specificity that the payer requires.

Insurance must be verified prior to any service because pre-authorization is required for many plans.

While Medicare recently increased the demand for proof of medical necessity beginning Jan 2018, private payers have also adjusted their demands for individual policies resulting in confusion of requirements and increased claims denials. According to the MGMA poll in Sept. nearly 86% of practices polled said that they have experienced increased denials due to payer policy changes regarding prior authorizations.

Not all insurances are equal

Insurances have multiple plans that stipulate different coverages. Some plans only pay for specific services, some will only pay once a patient has paid down a specific amount, or after a certain length of time.

Regarding medical billing and coding, depending on the service, the coding/billing representative may need more information or historical documents in order to work the denied claim.

At MEREM Healthcare Solutions, we want to be your strategic partner in making sure your billing, coding, auditing, and other needs are met. Contact us today to learn how our knowledgeable and experienced professionals can help assist with issues associated with EMR and medical billing among your medical facilities.