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The Pre-Authorization Story

Once upon a time, a practice could forget to get a pre-authorization or maybe exceed the scope or maybe even provide the pre-authorized service on a different day and the carriers would allow for retro-authorizations so the claim would be paid.  Fast forward to today and the insurance carriers are not so forgiving. Many take the position that you didn’t follow the rules so too bad you just provided the care for free.

Insurance verification and pre-authorizations are a vital part of your practice.  A large percentage of denials are due to missing pre-authorizations or pre-authorization errors.  A patient should never be scheduled for services until benefits are verified and pre-authorizations are in hand.

What is a pre-authorization?

There are many terms used for pre-authorization such as, “prior authorization”, “pre-certification”, “prior approval” etc. Though these terms vary slightly, the process they refer to is all the same. It’s a process where healthcare professionals are supposed to request confirmation from the insurance company that they will cover the prescribed medication, service, or treatment for the patients.

A pre-authorization is not a referral, and a referral is not a pre-authorization.  A referral is generated by the primary care physician when referring to a specialist.  Several insurance companies require that a patient have such a referral prior to seeing the specialist.  The referral is only for the consultation.  The specialist must obtain a pre-authorization for additional services.

But what if we didn’t get pre-authorization?

Fighters have a saying, “don’t leave the decision up to the referee”?  That means they want to win decisively.  They don’t want to leave any doubt as to who won.  The same holds true for pre-authorizations.

If you forgot to get one, didn’t know you needed one, or thought you could get it after the service date, or maybe submitted the wrong date or CPT you have left the decision with the carrier.  The decision to issue retro-authorizations now depends on the insurance carrier’s policies.

Once the insurance carrier denies the retro-authorization there is no recourse, and the healthcare provider has rendered the care for free.  And, in some cases, your contract with the carrier prohibits you from billing the patient directly.

How to get a pre-authorization

A frustrating fact is that there are no standards that dictate how one goes about obtaining a pre-authorization.  The process varies from carrier to carrier and even state to state. But there are some general guidelines.

  1. Gather all the necessary documentation to support the service. This will include what the healthcare provider believes will be the next course of action and the rationale behind the treatment plan.
  2. Pre-Authorizations are given for specific services on specific dates so make sure you have accurate CPT codes and know the dates of service. Even the slightest mistake will result in denied services.
  3. Contact the insurance carrier and they will instruct you on how to submit the pre-authorization request.
  4. It can take up to 10 business days to approve or deny the pre-authorization. If the request is complete and is included in the patient’s plan, then an authorization number will be given.
  5. This authorization number must be included on the claim so the claim will be paid.

Whatever you do don’t take the verbal approval of an insurance employee.  Always, always get a pre-authorization number.  Yes, this process is time-consuming but if done consistently and accurately your claims will be paid.

Patient Privacy in the Digital Age

The digital age opened a Pandora’s Box of new threats and security concerns for all businesses—especially clinical practices. Federal agencies, like the National Institute of Standards and Technology (NIST0, and legislations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), drive guidelines and requirements for protecting patient records and confidentiality. And because employers are held accountable for the actions of their employees, the stakes are even higher for ensuring the integrity and security of patient information. Strong privacy and security policies and procedures must be established and followed.

But what about the financial records of patients? Isn’t this information also protected? The answer is “Yes, of course.” So, what can you do to protect this aspect of your practice?

Consider first that every time you recruit and train a medical biller for your office, you are opening the records to a new person—a new set of eyes. Second, it would not be uncommon for this new employee to make errors, especially while training. Manual data entry is always prone to human misunderstandings and mistakes.

Secondly, it depends on the type of software you are using and whether it is cloud-based, or a local server is used.  Is the data backed-up, is it a redundant back-up and if it is backed-up where is this done?  Is the technology encrypted?  All of these questions are key to ensuring that all of your data, including the financial data, is protected.

By outsourcing your billing and collections to Onpoint Medical Solutions, we ensure the security of your patient financial records. Staying ahead of the current medical office software platform requirements and changes within the industry takes awareness and time. Partner with us to make sure your patient financial records are secure, your staff costs are low, and your revenue is maximized.

Got stress? Try this…


Many times, we have heard clinic staff, providers and even patients say they are stressed. Maybe even friends and family have expressed that they feel tired, sluggish and have a general lack of enthusiasm. Everyone knows that exercise can help but when do you find time to exercise? Sheila Johnson of WellSheila has some suggestions that may help. You don’t have to be a yoga enthusiast or even someone who has tried yoga in order to benefit from these 5 tips.

By Sheila Johns, Contributing Writer

Working in the healthcare industry is stressful no matter your niche or area of expertise. But incorporating yoga into your everyday life can help ease your stress, boost your activity level, and help you feel refreshed for your next shift.

Yoga can be restorative, relaxing, and a challenging workout. But if you’ve fallen into a bit of a rut, it might be time to explore ways to launch your practice to the next level. From incorporating tools into your routine to trying out new technology or equipment, there’s so much you can do to boost your yoga program, even as a busy healthcare professional.

Enlist Expert Help to Get Started

Whether you’re new to yoga or want to learn more advanced poses, getting expert advice may be ideal. After all, you don’t want to sustain an injury or perform a pose improperly to the point that it’s ineffective in terms of building muscle or stamina. Choosing a teacher can help you learn each pose the right way, plus help you break out of your comfort zone a bit. And with the arrival of distance yoga classes and apps for instruction, you can take your yoga teacher everywhere you go.

Add Props and Equipment

One of the obstacles to a yoga routine that builds up momentum is the difficulty of some poses. By adding equipment to modify the positions, you may be able to master something new – and build on your prowess over time. Eventually, you may not need props like a rolled towel, blocks, or even a chair or wall for balance. Just remember to take it slow, loosen up, stretch it out, and don’t push your body past its natural limits. You’ll get there in time!

Try Reverse Psychology on Yourself

This tool is a bit of a psychology trick, but it’s an effective way to stay consistent yet forgiving with your yoga routine. The overall idea is that failure is okay sometimes and that you don’t have to be perfect or even 100 percent committed to reap the benefits of the exercise. Telling yourself that it’s perfectly fine to take days off or modify your routine to make it easier or shorter can help you maintain energy to stick with it long-term. And the nicer you are to yourself, the less you’ll want to give up, points out Psychology Today. After all, the better you feel, the more passionate you’ll be about your fitness habits.

Challenge Yourself with Goal Setting

Reaching your goals feels rewarding and empowering, points out Artful Agenda – but what if you don’t have any goals to aim for? Setting a challenge can help you stick to a regular yoga habit, but it can also elevate your practice to the next level. Maybe you want to hit a weekly or monthly goal for time spent in a specific pose, or maybe you’re hoping to master a particularly challenging move for the first time. Whatever your goal is, track it on your phone to keep apprised of your progress.

Employ Focused Meditation (versus Spacing Out)

Yoga can be so relaxing at times that you might start to feel a bit spaced out. While relaxation is essential, utilizing your yoga practice for more focused meditation offers benefits, too. Make the most of your quiet time to reflect inward and follow guided meditation steps while holding each pose (and keep meditating during other activities, too). After all, mindfulness helps you remain grounded, which is one of the focal points of yoga. Combining meditation with yoga benefits both your body and mind, at the same time.

Are Denied Claims Costing Your Practice Money?

Are you losing thousands of dollars each month? Practice owners review many valuable metrics that help monitor the practice’s finances. Some industry experts say the key metric is the clean claims ratio and insist it is essential for real success.

What is a clean claim?

A clean claim is one that was paid by the carrier the first time the claim was submitted. This means that the claim

  • Had no errors.
  • Was never rejected; and
  • Was not filed more than once.

Some software solutions have various ways this can be measured and some billing companies under-state the denial rate because they reset the claim submission date. Although this produces a favorable metric it is not accurate. Measuring this number in the strictest sense requires evaluating every denial to determine whether it was preventable.

If your billing service is measuring this ratio accurately, they can then suggest ways to improve and eliminate the denials that are preventable. This is extremely important for the financial wellness of your practice because clean claims increase revenue by ensuring that you are not providing free care and ensure a timely and steady stream of revenue for your practice.

Every rejection or denial introduces the risk of not getting paid. Assuming the denials are worked it still delays you getting your money in a timely fashion. According to the Medical Group Management Association (MGMA) 50% to 65% of denials are never worked. These are the hard dollars to collect and require time, tenacity, and knowledge. Studies show the average cost to rework a claim is $25 and in many cases is far too much to expect of in-house billers and billing services may not deem it to be cost effective.

Are you losing thousands of dollars per month?

If the average cost to rework a claim is $25 and you have 100 denials per month then it costs an average of $2,500 a month to work denied claims. This is one reason that some billing companies charge less but return denied claims to the practice. This means someone must enter the rejection or denial, call the payer for details, research whether the carrier is, in fact, correct, correct the mistake, and refile the claim. Many payers only allow you to research three denied claims per phone call and they don’t always tell you if there were multiple reasons that claim was denied.

When assessing practice management systems and billing services, ensure that you are getting accurate clean claim ratios. This is not the same as first-pass ratios. First-pass ratios typically refer to the ratio of claims that make it through clearinghouse edits and are passed on to payers. It does not guarantee the claim will be paid.

The key to reducing denied claims

Make sure you are getting a report/input from your billing service that identifies denials.

Are you getting denials for non-covered services? If so, is there another clinically accurate code that can be billed or are you providing services for which you cannot be paid. Are the denials related to information the front desk is not capturing correctly? Using automation to its fullest extent can also help to monitor pre-authorization compliance. Bundled services will also be denied and you will get paid only on the lesser of the two charges.

These are all opportunities for improvement. Educating the entire practice to the cost of unclean claims and giving everyone feedback about what they can do to improve can go a long way to decreasing denials and maximizing your reimbursements and cash flow. If you aren’t getting this information from your billing service talk with them about obtaining such information monthly. It truly is a team effort to decrease denials. Ultimately, this reduces cost and increases revenue, which are keys to survival in today’s changing healthcare landscape.

Communication is at the Heart of Customer Service

Have you ever considered what your patients see, hear and feel when they come to your office?  Providers know how to give excellent care but is that enough to keep them as a patient?  From the patient’s perspective what is good customer service?  Linda Scheele, a contributing writer, provided insight into good customer service through the eyes of a patient.  It is definitely worth sharing.

By Linda Scheele, Contributing Writer

You’ve heard it said that real estate is all about “location, location, location.” But when it comes to customer service, it’s all about “communication, communication, communication.” Professional and personal relationships succeed or fail based on how well you communicate.

In a physician’s office, your team is already starting from a point of disadvantage because a patient is arriving at your door with an illness or injury. They may already be in pain or anxious about the visit. Those first impressions from a patient’s point of view are critical. A patient feels welcome, safe, and cared for when there is good communication.

First impressions. Whether the first point of contact is the practice’s website, or a call to the receptionist, tone and language matter.

  • A website that is professional, well organized, and easy to navigate, instills confidence in a patient. The underlying messages are “These people know what they’re doing” and “This office makes it easy for me to … schedule an appointment … see their locations and office hours … understand their services.”
  • Personal contact with the receptionist, nurse, or doctor, is just as important in building confidence in patients. A patient feels welcome and, even special, when you remember their name as they walk through the door. Good eye contact is important. If you multi-task while the patient is speaking with you, it sends the message that you’re too busy for them and don’t really care. It also sends subtle messages like the office is too busy and not well organized.

Safety. In these days of COVID-19, communicating safety begins with the office following guidelines. A patient isn’t usually upset by having their temperature taken upon entering the office, or being required to wear a mask, etc. In fact, it helps them feel protected and assured that their safety is your number one priority.

Respecting time. Communication also comes in the form of respecting the patient’s time. Letting them know that the doctor is running behind, as soon as they arrive, helps them know what to expect. They don’t start wondering whether you forgot to call them, or if they are ever going to be seen by the doctor. On days when the doctor is way behind schedule, calling the patients ahead of time to see if they want to reschedule, also shows that you respect their time spent traveling to and from the office.

Non-verbal communication. Communication is also about knowing when not to communicate. A patient feels respected and protected when the office or physician manages privacy matters such as healthcare and finances with the utmost care and confidence. This is especially important at the front desk because the patient doesn’t want everyone in the waiting room to know about their ailment, or that they are having trouble paying their bill. Speaking with them out of earshot of others, or speaking more softly, lets them know you care.

An office that communicates well with its patients is an office where patients and staff thrive, patients refer family and friends, and the practice does well.

George Bernard Shaw once said, “The single biggest problem in communication is the illusion that it has taken place.”

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