Authorization is crucial to complete the claiming insurance amount. It refers to a process in which a healthcare center obtains approval from the insurance companies before conducting medical practices. The authorization is a complex and time-consuming part of medical billing and to complete it, one requires a highly experienced staff of medical billing experts. Come with me to explore authorization in medical billing, its types and see what happens if the authorization is not done.
Why Authorization Is Important for Medical Billing?
Basically, authorization is a bridge that links both the medical services provider and the insurance companies. As the name suggests, it is a process in which a healthcare center obtains approval for an insurance company to provide the services. Actually, when a patient is admitted in a healthcare center, the staff members ask for the billing method.
If the patient is enrolled in an insurance program, the medical professionals gather information related to the insurance company, the plan he has subscribed as well as other details like what services he requires and the expenses the insurance program can cover. Instead of providing the services to the patient, the medical professionals contact the insurance company to know whether the information provided by the patient is accurate.
Here, begins the authorization in medical billing when the insurance company checks the details and then verifies the information provided by the patient. It helps confirm that the proposed treatment or the services by the healthcare center are necessary and adheres to the patient’s health plan policies.
Pre-Authorization in Medical Billing
There are several types of the authorizations but the most crucial one is the prior authorization when the medical services provider obtains approval form the insurance companies before beginning the process of treatment or services. It is not only important for the healthcare services providers but also for the air nuance companies and the patient so all of them do not face challenges after completing the process of treatment.
Majority of the people consider that the prior authorization is a compulsory step. However, the nature of its necessity depends upon the type of the plan of a patient. In case, the plan does not require prior authorization, the healthcare center will not waste time on verifying the details. Additionally, it depends upon the rules of the insurance companies as the majority of them argue that all healthcare professionals should confirm the details before providing the services.
Types of Authorization in Medical Billing
There are three major types sof the authorization including the prior authorization, concurrent authorization as well as retroactive authorization. Each one is unique based on the demands and the plans of insurance a patient has subscribed. Let’s see each of the in detail:
1. Pre Authorization in Medical Billing
The top one is the prior authorization that is conducted before beginning the proceed treatment. The pre-authorization is a complex task that requires the medical billing professionals to gather the details of a patient relevant to the insurance program. Pre-authorization included submitting the patient information, diagnosis codes, and service details to the insurance payers.
Components of pre-authorization
Patient Information: It begins with gathering the information of the patient such as the name, address, contact details, age, and the insurance company or ID document.
Service Details: The healthcare center submits the details to the insurance company about the requested services, which include diagnosis, treatment, medical tests, surgery services, and care needs.
Medical Necessity: The insurance companies do not act upon the submitted details but require proof that the patient requires all the required services.
Payer Policy: Health Care centers go through the payer policy of an insurance company because each company has policies based on its payer policy.
2. Concurrent Authorization
Another type of authorization is known as the congruent authorization in which the healthcare provider applies for the authorization from time to time. It is also necessary when the patient requires extended treatment, surgery, or emergency services during the treatment. To confirm whether an insurance company will pay for extended services, a healthcare center applies for concurrent authorization.
Components of Concurrent Authorization
Initial Review: It begins by studying the documentation so that healthcare professionals can assess the necessity of ongoing care.
Real-Time Monitoring: It requires monitoring the process of treatment 24/7 in order to assess extended services.
Proving Proof: A healthcare center must give proof to ensure the need for extended services.
3. Retroactive Authorization
It is a type of authorization that is submitted after providing the medical services. Normally, retroactive authorization is required in case of immediate medical services or emergencies. For example, if a patient is going through a medical treatment that is authorized by the insurance company but suddenly he develops kidney issues or the chances of heart attack increases. In these cases, the healthcare providers will give the treatment and then submit the documents for authorization, that’s why it is known as retroactive authorization.
Components of retroactive authorization
Submission: It is submitted after providing the services to a patient.
Denial risk; The risks of the diesels in the retroactive authorization are high compared to the prior authorization.
Timeline Compliance: The healthcare provider must ensure that the authorization appeal is submitted within the payer’s allowed period.
Who Gives Authorization in Medical Billing?
In medical billing, authorization is given by the insurance company of the patient. This process entails feeding the healthcare provider who in turn presents the required paperwork and payer who in turn analyzes the request in view of the patient’s policy and medical necessity.
The Authorization Process
The application is started by the healthcare provider who sends a statement to the insurance company which can include clinical notes, diagnostic tests, and treatment plans. Insurance organizations compare the data to determine whether the service corresponds to the medical necessity and is included in the patient’s plan. If an application is accepted, an authorization number is provided and it has to be provided for submitting claims.
Denials and Appeals
In case the authorization request is turned down, the provider or the patient has an option of reconsideration. This requires providing more information about the patient’s condition or there could be misunderstandings arising out of the patient’s condition or the treatment plan. An appeals process is set in place to allow all parties a shot at addressing the issue before anything is final and if there are any discrepancies, it helps resolve them to make a final decision.
Referral and Authorization in Medical Billing
Another factor of the authorization that can cause several issues is the referral. It is a process in which a physical sends a patient to another expert which is known as a medical referral. The issue with referral is that some insurance companies have a policy that if a psychic is referring a patient to another then, it must be proven that the referral was compulsory.
Process of Referral and Authorization in Medical Billing
Request Submission: A referral or authorization is a written recommendation from the healthcare provider to either the specialist, for referrals or an insurance company for authorization, enclosing patient information and the kind of service the patient requires.
Patient Information: Referral and authorization both need general patient information like medical history, disease, and purpose of referral or service to enable correct treatment and insurance.
Insurance Review: The insurance company reviews the provided info to determine if the service, or specialist visit, is necessary and is covered by the patient’s insurance.
Approval or Denial: In light of the review made, the insurance company accepts or declines the request made by the assessor. When granted, an authorization number is issued for billing. If refused, the provider may appeal against the decision given.
Call for Action
Authorization is a complex task that requires an abundance of hard work and the use of excellent tools. Not only this, a group of assessors is also required to request pre authorization and here you should contact Med Brigade, of the best medical billing and coding company. The chances of denials are zero and the process will be completed in a short period compared to the required time. The Med Brigade team of experts will take your business raven to the next level by reducing the girls of denials. Our professional team of medical billing and coding experts at Med Brigade will enable file robust appeals of authorization and follow up the process. Contact Med Brigade for the authorization services whether you have a small scale or large business.
Conclusion
Med Brigade is the best company for medical billing and coding processes. The team of Med Brigade knows the complexities a healthcare provider might face during conducting the prior authorization tasks and we have experts who handle denials. Authorization is an effort requiring tasks and only professionals can work on it therefore partner with Med Brigade to get excellent authorization in medical billing services.