Prior-Authorization

Triump Health provides Prior-Authorization services to assist healthcare providers in obtaining prior approval for medical procedures, treatments, or tests from insurance companies.

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MEDICAL BILLING & REVENUE CYCLE MANAGEMENT

Prior-Authorization

In our experience working with medical practices, we have observed that a large number of denials happen because a patient is not eligible or authorized for services billed to the payer. We help you to dramatically reduce the prior-authorization denials, by obtaining prior-authorization well before the patient’s scheduled appointment. Therefore, the patient’s obligation is clear and available at the point of service, thus accelerating the payment before the visit even begins. In addition, it helps in filing clean claims, resulting in reduced accounts receivable days and increased collections.

Frequently Asked Questions

What is a prior authorization in the context of healthcare, and why is it necessary?

Prior authorization in healthcare refers to the process where healthcare providers obtain approval from insurance companies before delivering certain medical services or procedures. It is necessary to ensure that treatments or procedures meet specific criteria for coverage, controlling costs, and preventing unnecessary or inappropriate healthcare utilization.

How does the prior authorization process work, and what information is typically required for submission?

The prior authorization process involves healthcare providers submitting requests to insurance companies, typically including patient demographics, medical history, diagnosis codes, procedure codes, supporting clinical documentation, and sometimes provider notes. Insurance companies review this information to determine if the requested service meets their coverage criteria.

What are the common challenges or delays associated with obtaining prior authorizations, and how do you address them?

Common challenges or delays associated with obtaining prior authorizations include lengthy approval times, administrative burdens, complex requirements, and potential for denials. Healthcare providers can address these challenges by employing dedicated staff, utilizing electronic submission systems, maintaining clear communication with payers, and staying informed about payer policies.

Can you provide information on the impact of prior authorizations on patient access to timely medical treatments and procedures?

Prior authorizations can impact patient access to timely medical treatments and procedures by causing delays in care, increased administrative burden for patients and providers, and potential barriers to accessing necessary services. Delays may result in worsened health outcomes for patients.

What steps can healthcare providers take to streamline the prior authorization process and minimize delays for patients?

Healthcare providers can streamline the prior authorization process and minimize delays for patients by implementing electronic prior authorization systems, conducting thorough eligibility verification upfront, maintaining open communication with payers, educating patients about the process, and advocating for streamlined authorization processes with insurance companies. These steps can help improve patient access to timely care while reducing administrative burdens for both providers and patients.

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What Makes Revenue Cycle Management Services Different?

TriumpHealth prior-authorization services include:

Submitting prior-authorizations to payers proactively
Timely follow-up on prior-authorizations not received or denied
Working with the practice to gather letters and templates such as:

Description of procedure letters
Medical necessity letters
Description of unlisted drugs or procedures
Appeals templates

Medical records submission as needed for prior-authorization processing
Field phone calls from payer clinical staff
Provide clinic feedback to the practice on payer guidelines and requirements

Our Process

Documentation Collection

Gather all necessary documentation including patient medical history, diagnosis information, treatment plans, and supporting clinical documentation required for the prior authorization request.

Submission and Follow-up

Submit the prior authorization request to the relevant insurance company, ensuring completeness and accuracy of the information provided. Follow up with the insurer to track the status of the request and address any additional requirements or inquiries promptly.

Appeal Process

If the prior authorization request is denied, initiate the appeals process by reviewing the denial reasons, gathering additional supporting documentation if necessary, and submitting a comprehensive appeal to the insurer within the specified timeframe.

Documentation and Communication

Maintain detailed records of all prior authorization requests, submissions, and communications with insurers, including denials and appeals. Communicate with healthcare providers and patients regarding the status of prior authorization requests and any necessary next steps.

Benefits of Working with TriumpHealth

Prior Authorization

Reduced Claim Denials

Our proactive prior authorization before rendering medical service results in successful claims processing and higher reimbursement.

Avoid Costly Appeals

We have a lower rate of appeals per claim billed because of higher prior-authorization approvals.

Lower Resource Allocation

Higher prior-authorization approvals helps us in efficiently leveraging billing resources to improve reimbursement.

Higher Patient Satisfaction

Lower cancelation of appointments due to preemptive prior authorization approvals increases patient satisfaction.

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We will help you achieve financial and regulatory compliance goals resulting in improved patient outcomes and increased revenue.

Prior-Authorization