Tuesday, May 21, 2024

prior authorization question/comment


Has anyone noticed the increase in the numbers of payers who outsource their prior authorization process? I have.

These PA folks are large companies who serve many different payers. They employ nursing types who “verify” only medical necessity. This strategy further separates a “prior authorization” from the actual payment of the claim. Not good.

To re-state some of my post from last year, a paradigm shift needs to occur. True cost containment with quality care will only occur when payers, providers, and suppliers actually work together fairly. Industries and professions like ours need to influence the future look of cost containment. Cost containment is more than shifting revenue from providers and suppliers to other entities (payers and third, fourth, or fifth administrative parties). I hope small business (folks like me), big business (POINT, Reliacare, Hanger, etc.), AOPA, BOC, etc. will all help in this necessary process. Orthotists and prosthetists should be treated fairly and with the same good faith with which they care for their patients.

The outcome of pre-service communication with a third party entity needs to provide value. The semantics of pre-authorization, prior authorization, authorization, pre-certification, pre-determination, and so on are irrelevant. An “authorization” that contains the standard statement “this authorization is not a guarantee of payment” is virtually meaningless. Knowing what a third party will pay on behalf of the patient is what allows appropriate business to transact.

The payers obviously need to consider medical necessity for the ordered services as they relate to the noted diagnoses and procedure codes. However, the payers also need to consider any plan provisions/terms/limitations, any implications of network status of participation, the status of deductibles and co-pays, etc. Specifically, the payer needs to determine and state what the guaranteed payment will be if the insured is eligible for coverage on the date services are rendered.

The payer will always do the determination; it just needs to be done pre-service not post billing. The patient and provider of O and P services deserve usable information. There is a significant cost to the orthotist and prosthetist in providing service and the financial responsibility for the patient has to be understood up front so appropriate decisions can be made. When a third party payer is involved, accurate, usable, and reliable facts are what matter.

Douglas Van Atta, CPO


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