Prior authorization requirements are a burden on both physicians and patients. Although pre authorization often delays care for patients, without getting authorization, providers don’t get reimbursed for the medical services they provide.

This makes prior authorization and the processes leading to it extremely important. As physicians are usually burdened with clinical work, the responsibility of completing prior auth requests on time is passed on to non-clinical admin staff. At smaller practices, these administrative staff members are tasked with patient registration, insurance verification, coding, billing, and claim submission. As these admin functions require specialized knowledge, it is best to hire staff that have experience in the roles they will be performing.

To get around this problem, most healthcare providers have started outsourcing their PA operations to an experienced prior authorization company. And so, to help providers decide on which pre authorization company to partner with, we will discuss important factors to consider when selecting a PA company.

  • Experience & Expertise: It is important to validate the expertise of the companies that provide prior authorization services. Providers should look for the medical specialties, years of experience, and expertise in securing prior authorizations from different payers across different states. This is because prior auth requirements vary based on the type of medical specialty, associated payer, and local/state regulations.
  • Certifications: Prior authorization companies should acquire proper industry certifications before they can offer their services to healthcare providers. These certifications validate that the pre authorization company complies with all healthcare industry rules and regulations. Some general certifications include HIPAA, AAHAM, CRCP, and CPC.
  • Accuracy: When outsourcing pre authorization operations, it is important to check the accuracy score of the prior authorization company. The accuracy score across the industry ranges from 93% to 98% depending on the expertise of the PA company. However, an accuracy percentage of 95% and above is generally considered very good.

 

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  • Productivity benchmarks: Another crucial indicator to check when selecting a prior authorization company is its productivity metrics. Productivity metrics allow providers to understand benchmarks like how many PA requests can be completed by one FTE every hour. It also gives them an idea about other related performance benchmarks. As prior auth requirements are different for each provider, it is best to ask for metrics that address specific requirements of the healthcare organization.
  • Cost-effectiveness: One major reason why healthcare providers are looking to outsource their PA operations is because maintaining an in-house PA team is becoming expensive. This is because of the recent increase in minimum labor wages across some states in the US.

For more information on key metrics or to learn more about why providers across the US hire a prior authorization company, please contact Sunknowledge, a healthcare prior authorization company that has been offering revenue cycle management services.

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