Frequently Asked Questions
1. Prior Authorization
Q. What is prior authorization?
A. Prior authorization — also frequently referred to as preauthorization — is a utilization management practice used by health insurance companies that requires certain procedures, tests and medications prescribed by healthcare clinicians to first be evaluated to assess the medical necessity and cost-of-care ramifications before they are authorized.
The reasoning behind prior authorization requirements is that a less expensive treatment option may be sufficient rather than simply defaulting to the most expensive option. This is especially true for high ticket procedures and medications like surgeries that can safely occur in the outpatient setting, MRIs, durable medical equipment (DME), and specialty drugs.
For medical services, health plans may steer patients to lower cost physicians or sites of care. For medication — especially high priced specialty drugs — pharmacy benefit managers (PBMs) often require a step therapy approach which dictates starting with less expensive options before stepping up to more expensive medication.
The decision by a health insurance payer to approve or reject a prescribed course of treatment based on the results of a prior authorization review will affect whether a provider or pharmacy will be reimbursed for a claim and, if so, whether reimbursement will be for a full or partial amount.
Q. What is the difference between preauthorization and prior authorization?
A. Preauthorization and prior authorization are often used interchangeably and refer to the same thing, as do terms like prior notification and prior review.
Q. What is the difference between prior authorization and a referral?
A. A referral occurs when a referring provider recommends a patient to another provider to receive care, often in another specialty. This requires that the ordering provider submit paperwork to authorize the appointment.
Q. How long does a prior authorization take?
A. Depending on the complexity of the prior authorization request, the level of manual work involved, and the requirements stipulated by the payer, a prior authorization can take anywhere from one day to a month to process. The 2018 American Medical Association (AMA) Prior Authorization Physician Survey revealed that 26% of providers report waiting 3 days or more for a prior auth decision from health plans.
This delay can cause problems for both patients and the healthcare professionals attending to them. Patient adherence to medication and treatment often declines when obstacles like postponements or additional steps are introduced. It also siphons off time from clinicians — and the revenue cycle team that supports them — that could be better spent on patient care. As an unintended side effect of delayed care while a preauthorization is reviewed, some patients will seek treatment at an emergency room; a decision that will often result in them receiving a large, unexpected bill not covered by their health plan.
Q. How does prior authorization work?
A. The current prior authorization process typically resembles the following flow:
1. First, a healthcare provider determines that a patient needs a specific procedure, test, medication or device.
2. The onus is on the provider to then check a health plan’s policy rules or formulary to determine if a prior authorization is required for the prescribed course of treatment. If it is required, the provider will need to formally submit a prior authorization request form and sign it to attest that the information supporting the medical necessity claim is true and accurate.
3. Because clinical and healthcare billing systems are rarely integrated, provider staff will often start by manually reviewing prior authorization rules for the specific insurance plan associated with the patient. The rules may often be found in paper documentation, PDFs, or payer web portals.
4. These payer rules are not standardized and differ from health plan to health plan. It is not uncommon for the rules to even differ from plan to plan within a specific payer. These payer rules also change frequently, so a provider’s administrative staff may be referencing out of date rules.
5. If the provider confirms that prior authorization is not required, it can submit the claim to the payer. This does not mean that the claim will necessarily be approved.
6. However, if the provider confirms that prior authorization is required, it will need to track down more specifics pertaining to each CPT code that is applicable to the prescribed course of treatment. It will also need to obtain a number assigned by the payer that corresponds to the prior auth request and include it when the final claim is submitted. These steps are usually done manually, often through a cascade of phone calls, faxes and emails between payer and provider.
7. The responsibility falls on the provider to continue to follow up with the insurance company until there is resolution of the prior authorization request — an approval, redirection, or denial. This part of the process is unstructured and often improvised, which often leads to significant wasted time and effort.
2. Appointment Scheduling
Q. What is an Online Appointment booking System?
A. Through a web interface, clients can book, reschedule, cancel, and even pay for services using an online booking system. Appointment schedulers are useful tools in the workplace. Many modern booking systems will also include a customizable online booking page that allows customers to book through social media sites like Facebook. Frequently, automated appointment reminders through SMS and email are added to such capabilities.
The popularity and demand for online bookings are growing rapidly, owing to the benefits it provides for both businesses and customers. Customers have grown to expect the ability to book services and appointments online. The ability to construct an interactive calendar is the major feature of the online appointment scheduling software. Potential clients can browse available time slots on the calendar and book an appointment online with ease.
For example, this app enables hair stylists, tattoo artists, massage therapists, and other service professionals to establish an online calendar that their clients can access and use to schedule appointments.
Q. To whom, is the online appointment Scheduling system suits for?
A. An online booking system may assist any service-based business, large or small, across a variety of industries, including Healthcare, instructors and trainers, cosmetics and spas, sports and fitness, and business professionals are among the areas that benefit. If you run a service-based business and want to develop it, improve revenue, and cut down on paperwork, an online booking system is for you.
Q. How to boost-up Online appointments?
A. 1. Promote your online appointment book.
2. Add a signature to your email
3. Customers that make reservations via the internet should be rewarded.
4. To make appointments, use social media.
5. Make use of Google MyBusiness
3. Eligibility and Benefits Verification
Q. How does a practice check eligibility?
A. Practices can use two different methods to verify eligibility — electronic real-time eligibility checks or manual checking. It is a best practice to use electronic real-time eligibility to run checks at least 48 hours before the patient’s appointment.
This method allows you to ...
1. Gain access to the patient’s insurance status and benefits prior to the visit.
2. Request updates from the patient and advise if a copay is due at time of service.
3. Verify updated insurance and ensure the account is notated for expedited check-in.
4. Ask patients to update their primary care physician (PCP) and coordination of benefits (COB).
While it is less efficient, manually checking eligibility may be necessary to ask the insurance company specific questions regarding the patient’s benefit plan. Simply call the insurance company’s contact number listed on the back of the patient’s insurance card or log into the payer’s web portal.
Q. What eligibility coverage information is provided?
A. The following information should be provided for every patient:
1. Subscriber name
2. Patient name
3. Patient’s relationship to subscriber
4. Patient date of birth
5. Patient gender
6. Patient member number
7. Group name and number
8. Plan type coverage date (policy effective date)
Beyond that list, payers may send additional information if available in the health plan’s records and appropriate to the coverage. This may include other insurance coverage in effect, PCP, and eligibility status. However, the accuracy of this information cannot be assured.
Q. When should eligibility be checked?
A. Practices should proactively check eligibility. The most effective time is before the patient is seen by the physician, ideally 48 hours before the visit. In the alternative, this process can take place anytime up until, or at, check-in. Front-office staff should always ask patients if their insurance has changed since their last visit.
Tip: Keep a current, legible copy of the patient insurance card(s) on file to reference during the billing process, as back-office billers may need to verify eligibility while working rejected and denied claims.
Q. What are eligibility verification best practices?
A. To decrease denials and potential delays in revenue, verify a patient’s coverage prior to the visit using your EHR’s electronic eligibility feature.
Beyond that best practice, follow this checklist prior to the visit:
1. Check for inactive plans and flag the accounts.
2. Check for primary, secondary, and tertiary insurance. When patients have multiple insurance plans, remind them to update their COB with each payer. (Note that Medicaid is always considered the payer of last resort.)
3. For patients 65 or older, it is always best to verify whether their insurance coverage is “traditional” Medicare coverage.
4. Confirm the services covered under the patient’s insurance policy and whether a referral or prior authorization is needed.
5. Ensure referrals and authorizations are approved, entered in the system, and linked to the correct visits.
6. See if a benefit limit is listed, specifying how much of the benefit remains. Some plans may have limitations for the dollar amount of each visit or the frequency and time frame in which the services must be delivered (e.g., a benefit limit of 12 visits, with a visit limit of two visits per month). Note that insurance plans may indicate that the provider should call customer service for psychiatric and substance abuse benefits information.
7. Determine if a copayment, coinsurance, or deductible payment should be collected.
When scheduling the patient, remember these steps …
8. Obtain as much demographic information as possible. Some demographic details (i.e., preferred language, sex, race, ethnicity, and date of birth) will affect Meaningful Use (MU) reporting. 9. Always ask if the patient has had a change in insurance, whether a new policy or change in coverage.
Q. What are the benefits of a standard operating procedure (SOP) for checking patient eligibility?
A. It is recommended that you create a SOP for the eligibility workflows you utilize daily. For instance, the guidance offered in the SOP can include a recommended talk track for the front office staff to use when requesting delinquent balances of patients. Documenting the processes that work for your practice will provide a knowledge bank for new employees to understand the steps required to complete tasks accurately and efficiently. Additionally, the SOP document will promote collaboration across the office by helping different roles understand how their actions influence the revenue cycle.
4. Patient Follow Up
Q. What is the accounts receivable process in healthcare?
A. Accounts Receivable (AR) is the money owed to Providers or medical billing companies for the medical care rendered to patients. The generated invoices are sent out to insurance companies or patients for payment. The staff must keep a tab on the AR and see if the payments reach on time. In simple words, the Accounts Receivable process is of identifying denied/unpaid claims, re-filing the corrected claims, minimizing AR days, and eliminating aged AR.
Q. The best strategies to improve collections
A. Analysis of collections by payer: It is necessary to identify which insurance companies are slower to pay and which ones have a higher volume of denials
Assessment collections from patients: The practice needs to collect all the copayments, prepayments, and outstanding payments at the time of service. Patients should be educated on the payment process before or at the time of service
Calculation of the frequency of errors that delay collections: Practices should take note of repeated errors in gathering patient data, coding, billing, or other processes. These are indications of the areas in which changes need to be made.
Leveraging the medical billing program: The software should be able to notify the staff when accounts are past due so that follow-up steps can be taken Involvement of staff: There must be a team to track specific payers; regular meetings should be called to discuss A/R status and problem areas, and identify collection techniques that work.
Q. A good stream of revenue
A. One of the main sources of revenue for a medical institution, such as a hospital, is the account receivable payments they get either from the patient or their insurance company. If a hospital can manage its A/R system properly, it will receive the revenue it needs to stay open and treat more patients.
Therefore, hiring an effective medical billing professional who specializes in A/R follow-ups will assure that your practice, clinic, or a larger healthcare facility is successful and equipped to treat more people.
Q. Easier and quicker payments
A. While certain federal and state mandates affect how quickly claims are processed, your medical billing specialists may shorten or lengthen the period between a patient’s account being charged and when its balance will be paid. What they also do is seek the accounts with outstanding charges and then discuss the best strategy for ensuring payment, then finally implementing it until the payment is secured.
Q. Increased Reimbursement Optimization
A. Another important purpose for a medical biller’s A/R follow-up service is that it can increase the chances of getting your medical service fully reimbursed. Some insurance payers deny claims due to some discrepancies in the documents sent along with the claim itself. Medical billers can commit a follow-up by directly contacting the insurer and requesting the precise reason for denial. If it was due to certain pieces of information missing from the claim, then a corrected claim can be filled and sent again, resulting in the A/R being paid.
5. Patient Collections
Q. What are the Patient’s payment options?
A. Most of the medical billing service companies offer all forms of standardized payment options that are accepted, including cash, check, and major credit cards. To pay by credit card over the phone, please call customer service. Patients may also pay in cash at the hospital or mail their payments to the payment address listed on the patient statement. Text-to-pay is another available option which is easy to deal with.
Q. Why do insurance companies pay only part of patient’s bill?
A. Most insurance plans require that you pay a co-payment, coinsurance or deductible for your health care expenses. Patients must contact their insurance company for specific information about their coverage.
Q. Why do patients receive bills for services provided long ago?
A. Medical billing services will process and send a bill to a patient after payment is received from the insurance companies with the confirmation that the balance is owed by the patient. The length of this process depends on how long it takes to receive a response from your insurance carrier, and whether there is secondary insurance.
Q. What should patients do when their insurance company changes?
A. When patients experience any changes regarding their health insurance, they will have to advise the hospital registrar at the time of service mentioning the same.
6. Credentialing with Insurance
Q. Why would someone want or need medical credentialing?
A. Being credentialed with insurance panels means that you are able to see patients who have specific insurance plans and bill those insurance companies directly for the services you render. This can greatly increase the number of patients who can access your services.
Q. Do I get to choose the Insurance panels I want to be on?
A. Yes. When you sign up for credentialing with us, you get to choose exactly which panels you want, and don’t want, to be credentialed with. Typically most outpatient physician providers credential with 7-8 payors, where as hospital based physicians (in-patient) usually credential with 10-15 payors (pretty much any patient with any insurance that comes to hospital). Physicians working in tristate area (border of 3 states) like in our physician owner practice credential with 25 payors.
Q. How can I track my Medical credentialing progress?
A. Your Credentialing Specialist will reach out at regular scheduled intervals to provide personalized updates. Our credentialing specialist reach out to the insurance providers every 2 weeks for updates.
Q. What are some of the more popular insurance companies?
A. The popularity of insurance companies varies depending on location. However, some of the most popular and largest insurance companies are Aetna, Cigna, Magellan, Tricare, United Healthcare, Humana, Value Options/Beacon Health Options, Medicare, and many others.
Q. How many hours of work does insurance credentialing take?
A. The amount of time that it takes to complete the credentialing process varies by license type. For a standard outpatient practice, the Credentialing Team will put in between 10 and 12 hours of work for each insurance panel. If an appeal has to be filed, that will add a minimum of 5 additional hours of work to that panel. Facility-based services, Home Health Care Agencies, and DMEs will all take over 20 hours to complete the credentialing process.
7. Medical Billing
Q. What Exactly Do Medical Billers Do?
A. A medical biller converts healthcare facilities into medical claimsand afterward sends them to insurance companies andpayers like Medicare and Medicaid. Medical billers must then follow up on theclaims to ensure providers obtain payment appropriately. Billing and coding are professions linked to these activities.
Medical coding includes knowledge of the method used to assign numerical codes to visits to physicians, hospital stays, and other procedures in health care.The basic tasks and the amount of time spent on each service would vary depending on the company. Generally,the services we provide at AuthorizeRx include:
1. Establishing patient payment arrangements and billing accounts for the job
2. Obtainingreferences and pre-authorizations as the procedures allow
3. Confirming eligibility and compensation for medications, hospitalizations, and procedures
4. Checking plans for patient follow up policies
5. Updating cash spreadsheets and running collection reports
6. Checking medical bills for consistency and completeness whileproviding any details that are lacking
7. Preparation, analysis, and forwarding of claims using billing tools, including the processing of electronic and paper claims
8. Following up on outstanding claims within the normal period of the billing process
9. Checking for consistency and compliance with contract discount on all insurance payments
10. If required, calling insurance firms in case of any difference in payments
11. Inquiry and appeal into all claims denials
12. Answering all patient or telephone insurance questions relating to specific accounts
In addition to the above, we also allow employers to request certain services theymight need that suit our skills and background experience or provide training for their staff.
Q. How Do You Get into Medical Billing?
A. We have spent years perfecting our service and process so we can deliver world-class service at all times. Our services include:
Input patients into the billing services management scheme. After searching for any missing information, we collect all the demographic information correctly for medical billing.
For any practice or medical billing company, the key to success is to ensure the services theyhave provided are paid for. Our medical review team of experts will confirm eligibility for the claim and keep you aware of your patient visits.
We understand the value of insurance authorizations for services and operations as a committed medical billing company. We get the approvals done in advance and make sure that you get paid.
Our certified coders know all specialties in medical coding. We are well versed in hospital/patient identification, emergency room e-code assessment, DRG / ICD-10-CM, CPT / ICD, HEDIS, and audits.
Being one of the largest US medical billing firms, our mission has always been to provide the industry with a reliable service. We manage Medicare and Medicaid requests, Workers Compensation, No-Fault / Personal Injury, and other big company insurance plans.
Our efficient medical billing organization is well versed in identifying and publishing insurance and patient payments. Our team is trained in making payment posts and ensuring that every line item is checked, certified, and posted to avoid loss of revenue.
Account Receivables Management
It’s necessary to appoint a dedicated team to handle A/R. The staff should be experienced in many specialties including insurance. Their duties are to administer A/R and negotiate claims while answering insurance and consumer queries.
When working with a medical billing business, monitoring is essential to transparency for every customer. AuthorizeRx offers information that is easy to access, and that can be tailored to your needs. We assign RCM managers to your account and have regular meetings vital for a healthy relationship to continue.
Q. How Do You Request Information from My Practice?
A. All of our clients have an email address they can use for a secure web log-in to our service. Through this medium, we can communicate with our clients and get responses when need be.
Q. Where Do the Payments Go?
A. All your payments and funds remain in your control. Customers must provide timely written notification of all collections they receive, including, but not limited to, patient cash payments, patient checks, payer checks, and EFT (Electronic Fund Transfer) deposits to AuthorizeRx. Our advice is to create as many payers as possible with the EFT (Electronic Fund Transfer) payments. The EFT payments will go directly into the client’s bank account, and our billing program will receive the corresponding ERA (Electronic Remittance Advice) through the clearinghouse. Checks will come in the mail to the client for deposits from payers who don’t use EFT payments. If there is no corresponding ERA, the checks and the correct EOBs will need to be reviewed and given to AuthorizeRx. We want to make as many claims electronically as possible, and we set up as many payers as possible to collect the payments through EFT.
Q. How Will You Work My Accounts Receivable?
A. A successful insurance model helps health care organizations recover outstanding payments from compensation providers quickly. This is when follow-ups to the receivable accounts (A/R) comeinto the frame. A/R management helps healthcare providers run their practice efficiently while ensuring that the money owed is reimbursed as soon as possible. Our account receivable follow-up team is responsible for looking after denied claims and reopening them to receive maximum reimbursement from insurance companies in a healthcare organization. It’s a thing of the past to have medical billing A/R and revenue cycle management handled by an internal team. Today it calls for our billing specialists with a broad skill set to take care of the A/R follow-ups.