Insurance verification and authorization is the first and probably most important step in the medical billing process. Patient eligibility verification involves checking out the patient’s coverage before services are provided. While checking patients’ insurance benefits properly is crucial, recent reports show that getting prior authorizations from insurance for prescription drugs can prove even more time-consuming and frustrating for physicians’ practices. Experts recommend that electronic prescription prior authorization could be an effective solution to the problem.
Payers use prior authorization to make sure patients get the right and most cost-effective medications for their situation. Medications that need prior authorization are those that:
- have dangerous side effects
- are harmful when combined with other drugs
- should be used only for certain health conditions
- are prone to misuse or abuse
- are prescribed when less expensive drugs might work better
- are lifestyle drugs or used for cosmetic reasons
- are covered by the health plan but are prescribed in a dose higher than “normal”
- are not usually covered by the health plan or pharmacy benefit manager (PBM), but deemed medically necessary by the physician
Currently, medication authorization is a time consuming and exasperating process for providers, their staff, and patients. An article published last year in Medical Economics pointed out that prior authorization of medications is not done at the time the physicians writes out the prescription. The typical procedure is as follows:
- Physicians prescribe medications but are usually unaware of whether they require prior authorization.
- Patients go to the pharmacy to get the drug, but are told that it needs prior authorization.
- The physician’s office is told about the need for prior authorization and, in 90% of cases, uses phone or fax to contact the insurance company.
- The payer will examine the clinical documentation and grant authorization after about 24-48 hours.
- The patient goes back to the pharmacy to get the medication after being informed by the physician’s office about the authorization.
This lengthy process is costly and involves a lot of work for physicians and their staff. It is also a harrowing experience for the patient.
To resolve these issues, technology companies have come up with tools to integrate electronic prior authorization in the e-prescribing process. In the electronic model, physicians would be able to find out which medications need prior authorization and inform patients in advance. Patients may be able to get a prescription approved while leaving the physician’s office. According to these technology experts, making these tools part of the clinical workflow by embedding them in the electronic health records (EHRs) will do away with time-consuming manual prior authorization processes. This will save time and money, reduce administrative burden, and improve both patient and provider confidence and satisfaction.
The electronic claims processing services that professional medical billing companies provide is fast, affordable, and highly efficient. So experts point out that there is no reason why the electronic prior authorization model shouldn’t work too. Of course, fully automated prior authorization may take time to implement. Till then, the best option for busy physicians would be to rely on established outsourcing companies for insurance verification and authorization and electronic claims processing support.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.