Posted by: Jenny Laurello
ICD-10, Prior authorization
Guest post by: Baskar Mohan, Director, Healthcare Practice, Virtusa Corporation
Prior authorization, or in short, prior auth, is an important part of the payer-provider-patient cycle of the health care market. When a provider or a physician determines that a patient requires medical attention or care, the role of the Prior Auth procedure comes into play. This procedure helps in streamlining and risk-optimizing the provision of the health care service. With the health care industry amidst the ICD-10 migration process, it is crucial for the providers and payers to incorporate prior auth into their plans.
Prior authorization has come to the forefront partly due to the cost savings it can bring to the payers and also its ability to approve procedures based on medical necessities. Providers, on the other hand, are burdened by the undue pressure placed on them due to the high number of services that must be authorized before they are performed. On the other side of the health care spectrum, patients are also frustrated due to the delay caused in the turnaround of the authorizations from the payers. In this blog I will focus on the impact prior authorization has on the provider community. Below are a few areas provider organizations should carefully consider as they move forward with their ICD-10 implementation programs.
- Diagnosis code submission – Diagnosis codes play a key role in the approval of prior auth requests. With ICD-10 implementation, these new codes have increased significantly and present a challenge to the provider who must use the correct codes for prior auth requests.
- Procedure code submission – Submitted ICD-10 codes need to match the procedure codes requested to ensure timely approval of authorizations. Incorrect mapping might lead to denials and non-payment.
- New procedures – Payers will have to train their employees, including auth requestors, on the new procedures (i.e., C-section), which might require prior authorizations. Since these are common procedures and do not require previous authorizations, it becomes a bottle neck for the staff to handle the huge volume of auth submissions.
- Authorization delays – Due to the existing manual process, information provided in the forms is not sufficient for payers to make a quick decision. Because of this, the payers end up calling the providers for additional information to approve the request.
- Medical coders – Existing medical coders need to be fully aware of the existing medical policies of the different payers so they can submit the correct diagnosis codes in the authorization as well as the associated claim. This ensures timely approval and payment of claims.
- Patient care – Due to payers requesting additional services for prior auth, delays caused in approving the requests due to the existing manual process and the introduction of additional codes with ICD-10 have put excessive pressure on the providers to supply the required patient care in time.
ICD-10 migration programs offer an opportunity for the health care industry to transform their operations. Prior auth is one such area in the overall provider-payer-patient paradigm that directly impacts stakeholders, which is why it is important to have a streamlined approach to make the process more inclusive and efficient. The above areas will help the provider organizations with their prior auth process efforts. How the organization defines and structures the process is up to them, but the bottom line is that organizations should be enhancing stakeholder involvement and satisfaction.