Authorization & Eligibility
Eligibility
& Benefit Verification
Eligibility and Benefit verification are important
components of a strong Revenue Cycle Process. Patient plans and benefits change
frequently, and it is important to establish a strong verification process
while simultaneously eliminating redundancies in the process that are not cost
effective. Lack of understanding 271 EDI results and poor processes can lead to
Revenue Cycle pitfalls and delay cash flow. It is important to have a very well
educated team. Our team of specialists consistently check for changes in
benefits and plans.
We verify a wide range of data:
- Effective
date and coverage details
- Individual
patient eligibility
- Type
of plan
- Payable
benefits
- Non-covered
procedures
- Co-pay
- Deductibles
- Co-insurance
- Claims
mailing address
- Referrals
& pre-authorizations
- Pre-existing
clause
- Max-daily
benefits
- Life
time maximum
- Other
related information
Our verification process checks procedure-specific
coverage and benefits along with all out-of-pocket costs so that patients are
aware of what is due before their visit. This process provides on-time patient
payments and prevents unnecessary back-end collections, effectively increasing
patient satisfaction and maximizing revenue.
Prior Authorization
While Prior Authorization is not a guarantee of
payment, it is an extremely important step in ensuring that authorization and
medical necessity requirements are met days in advance of the visit.
Establishing a strong Prior Authorization process is critical to patients
receiving care in a timely manner, provider satisfaction and eliminating the
chance of other denials i.e. medical necessity, frequency etc.
Our authorization process includes the following:
- Visit
dates should be within the effective and expiration date of the
authorization
- Some
payers require a specific appointment/visit date
- Appropriate
CPT and HCPCS codes are submitted
- Appropriate
levels are submitted
- Diagnosis
codes meet payer medical necessity guidelines
- Plan
of Care is well established and documented
- Diagnosis
codes are well documented
- When
applicable, the patient has undergone conservative treatment/therapy
- When
applicable, MRIs are performed and interpreted
- When
applicable the patient has had a psychological evaluation
- Establishing
Peer-to-Peer reviews
We work closely with providers to educate them on payer policy changes and prior authorization requirements. We also educate providers on the importance of documentation as it allows for quick authorization approvals and reduces the chances of authorization denials upon submission.
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