Significance of Pre-Authorization in Medical Billing and Claim Submission

Medical insurance companies frequently use the term "previous authorization." It means that, unless there is an emergency, a patient must obtain permission from the medical insurance provider before undertaking a certain medical procedure in order to be eligible for bill payment.

However, the insurance provider's decision to approve a prior authorization services is based on a number of variables, including the insurance limit, appropriateness, and medical necessity. There will be no reimbursement if you did not request prior authorization or if your insurance refused to provide you prior authorization. Contrarily, even a prior authorization that is granted does not ensure that you will receive a reimbursement from your insurance company.

What treatments/operations demand prior authorization or approval?

·         An insurance provider typically requests a prior authorization when:

·         A cheap alternative to treatment is conceivable.

·         If the patient's prior medical history makes the treatment ineffective for them.

·         If the procedure is being done for cosmetic or aesthetic reasons, it is not a treatment.

What role does prior authorization play in the approval of claims?

·         Prior Authorization is crucial for keeping the revenue cycle running smoothly.

·         Insurance companies and dentists collaborate to ensure effective financial management. Although occasionally the insurance companies detect discrepancy in invoices and want Prior Authorization to avoid paying anything extra out of pocket. As a result, it's possible that both the dentist and the patient will have to pay out of pocket.

·         Even when a claim has prior authorization, it may still be rejected. Therefore, it's crucial to comprehend the importance of prior authorization in the acceptance of claims. You must take certain actions, including the following, in order to have your claim processed:

Submitting a claim do include the unique Prior Authorization Number

Please make sure to mention the specific Prior Authorization Number when submitting a claim. There are therefore increased chances that your application will be rejected if the Prior Authorization Number is omitted.

By mentioning your Prior Authorization Number, you can simultaneously save time and money by reducing the likelihood that the claim will be denied.

Prior to treatment, obtain your authorization number

We are aware that obtaining a Prior Authorization Number prior to receiving treatment can be a lengthy process in and of itself. However, obtaining the Authorization number is also necessary. Particularly if the surgery is pricey and you don't want to pay for it out of pocket. However, in an emergency, the insurer might be a little more accommodating and pay the bills. However, before the operation in non-emergency situations, you must obtain an Authorization Number.

If only a portion of the treatment received prior approval

Patients occasionally submit claims for payment with their specific Authorization Numbers, however the claims are sometimes rejected. Ever ponder the reasons why? In most of these situations, the patients only receive consent for a single aspect of their overall treatment. Therefore, in order to use an insurance claim, the claim must be fully approved and not just partially.

Despite countless instances of meticulous work, the claim is still rejected. Approximately 80% of claims are rejected because they lack the appropriate authorization number. Please make sure to obtain the Prior Authorization Number prior to receiving treatment in order to have your medical insurance claim approved. In general, the Prior Authorization plays a big part in how smoothly your insurance claim is processed.

Are you looking to identify your short comings? Are you facing problems with your clinical operations? Then get in touch with medical practice consulting services.