The biggest cause of AR bloat (attributable to authorization procedures) stems from expired authorizations. Often times, authorizations are initially entered with only the minimal details necessary to setup (effective date, HCPCS and auth number). But to eliminate future headaches, we have to consider the end game and think through the eventual expiration and how many times the auth can be used. How will you know when a re-authorization is necessary? How will you know when the item should be converted to a purchase after reaching a cap? Most often, suppliers are not prompted to make these changes until we receive a denial.
To resolve this problem, we recommend establishing an “outtake” protocol where a team proactively scours your system for expiring Prior Authorizations to aggressively pursue re-authorization and cap conversions. For this to work, expiration dates must be entered initially when the authorization is set up. Then you can leverage reports in your billing system to identify expiring authorization and proactively pursue renewals and conversions.
Accountability is key. You need a point person to be responsible for the outtake process. They will need to proactively collect reauthorizations and convert capped items to keep claims moving smoothly. Having this process and lead in place will reduce denials and stabilize your revenue stream for items subject to prior authorization. They can run lead on mass migrations of authorizations when payers exit the business and another payer takes over, or when HCPCS change (like ventilators) and new auths must be secured for continued billing.
3.Leverage Your Billing Software.
At the end of the day, your billing software is just a tool that leverages data entered into it. Even if you obtain the authorization timely, if it does not get entered into the system properly, the claim will deny. If you are getting recurring denials for missing or expired authorizations, you have an education issue to address. Consider a refresher training for your staff (from intake to billing) on the steps required to secure, enter, edit, link, and send prior authorization information with your claims.
Draft a formal policy and write it down so it can be repeated. Having a written policy will maintain the integrity of the process and ensure information is shared consistently throughout the organization. Elain why the policy exists and what happens when it isn’t followed (revenue jams). Consider designating an authorization “expert,” so your staff knows who to contact in the event unique scenarios arise that don’t fit the mold.
Having a smooth process will provide you with a more consistent revenue stream. As the prior authorization model continues to grow among other payers, suppliers must claim more control over their exposure points. Leverage this opportunity to its fullest: be proactive, designate leadership, maximize your billing software, and be consistent.
Are you prepared for Medicare’s Prior Authorization Program for DME? Download our on-demand training to discover what products are affected by the rule, how CMS intends to deploy it and what the next steps are for implementation.