Pre Authorization Specialist Job Description


Author: Artie
Published: 2 Mar 2019

A Career in Insurance Pre-Authorization, The Prior Authorization Process in a Cancer Patient's Health Plan, A Notice of Reconsideration in HMOs and more about pre authorization specialist job. Get more data about pre authorization specialist job for your career planning.

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A Career in Insurance Pre-Authorization

Patients who need treatment for insurance carrier pre-authorization can be helped by a prior authorization specialist. They interview patients to assess their needs and work with insurance companies and nurse managers to get prior authorization. Medical clinic billing offices and insurance companies are where prior authorization specialists work.

The prior authorization specialists may become pharmacists with further education. Hours are spent at a desk interviewing patients, making phone calls and sending and returning emails as a prior authorization specialist. They may travel between branches if they work for a large organization.

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The Prior Authorization Process in a Cancer Patient's Health Plan

Before you can get a service or fill a prescription, you must get approval from your health plan. Pre-authorization, prior approval, and pre-certification are some of the names of the general process. When a service is not covered by a patient's health insurance plan, the prior authorization process begins.

Communication between the doctor's office and the insurance company is needed to handle the prior authorization. The insurance company may recommend a particular service based on patient factors that are clinically relevant, and the prescriber may need to complete a form or contact the company to explain the need. There is a

The prior authorization is reviewed by the health insurance company. The request can either be approved or denied. The patient or prescriber can ask for a review of the decision if the prior authorization was denied.

Delays in care due to prior authorizations could mean disease progression. In many cases, the drugs have to go through the prior authorization process. Patients with cancer have to endure delayed therapy due to the prior authorization process.

The process can take weeks to complete. Two weeks may seem like a long time to an outsider. Many physicians don't like the growing number of prior authorizations needed by insurance companies.

A Notice of Reconsideration in HMOs

An HMO member can get care from a hospital or specialist. Patients in HMOs need to get a referral from their primary care doctor before seeing a specialist. If the provider did not consult with them before making the adverse determination, they may request a new one.

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Electronic Prescription Authorization: A Challenge for Health Care Providers and Enterprises

PA is also referred to as precertification, prior notification, prior approval, prospective review, prior review, and the shortened form: "auth", as well as the more traditional "pre-cert, pre-auth and prior-auth" used by specialist. Have you obtained the credentials for that patient? The CAQH says that health care providers could save $7.5 billion annually by changing to electronic authorizations, but other groups say the savings to physicians are two to three times that.

The adoption rate for sending prior authorization digitally is just 8%, meaning that as of today, almost all of the pre-authorizations are being done manually. The inability of software makers to reconcile the incomprehensible variables of over 2000 health plans that each have their own prior authorization request form is the reason for the technology gap. The standard form for electronic precertification, the ANSI 278 Services Authorization, has been in place since 1996 and is now overseen by the NCPDP ePA data exchange standard.

A true beginning-to-end authorization solution requires a tight integration with a practice's billing and health care records. The current state of technology means that a hybrid outsourcing model is preferred, where a software application is used in the office to request and monitor PA status, while back end services are rendered by a team of PA experts that ensures each authorization is pushed through. A survey published by CoverMymeds found that providers who used only an electronic method for PA requests spent 2.5 fewer hours on authorizations each week, but that only 24% of respondents relied solely on ePA.

It is not easy for providers to find and implement an authorization system that fully manages the process, and that works with their existing practice management system and EHR. 98% of payers said they are committed to fully electronic automated solutions to help solve their determination process, but change is slow. PriorAuthNow is a cloud technology that helps providers get fast determinations, payers automate authorization determinations, laboratories automate complex authorization requirements, and manufactures increase patient access to specialty drugs, medical devices and equipment.

It helps reduce wait times for authorizations by having some come back in real time. All PA requests are submitted and monitored from a single location. Agadia PAHub is a HITRUST certified solution that streamlines the end-to-end management of prescription authorizations.

Automating Preauthorization for Cost-of Care Management

Preauthorization is a utilization management practice used by health insurance companies that requires certain procedures, tests and medications to be evaluated to assess the medical necessity and cost-of-care ramifications before they are authorized. If a health insurance payer rejects a prescribed course of treatment, it will affect whether a provider or pharmacy will be reimbursed for the full or partial amount of the claim. One of the main reasons that prior authorizations take so long to resolve is that incomplete or incorrect information is submitted to the health plan, which causes a denial and a lot of manual re-work on the provider side.

Errors in the prior authorization form can flag it for denial. A number on a patient's health ID card may be different. A middle initial may be wrong.

An address may be incomplete. The prior authorization process can be too complex and involve a lot of manual steps, which can make it ripe for mistakes. If any of the information is not accurate, the denial will be made.

It is difficult to reverse a denial. Automating the end-to-end prior authorization process early in the revenue cycle reduces the likelihood for errors, reduces the amount of manual work wasted, and speeds patient care. The decision a prior authorization request rests with a clinician who works for the health plan that submitted the request.

The clinician at the insurance carrier makes the final decisions. For more expensive, involved treatments, prior authorizations are usually required. Preauthorization is required for an procedure such as orthopedic surgery.

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