Prior-authorization also called pre-certification or prior approval, is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.
You must agree to payer pre-approval requirements to get paid. Although it’s impossible to be free from all hassle and frustration, but with the help of our Expert, Owen J. Dahl, MBA, FACHE, CHBC, LSSMBB, you will be able to make this process easier, faster and less stressful.
This concept is designed to save money, reduce unnecessary or duplicate procedures and testing from occurring. The jury is out as to the effectiveness of the process. It is expensive for both the payer and the provider and solutions need to be worked out. We will address the why and how but bring it to the level of the practice as to what is currently happening and what can be done to improve and “guarantee” payments for procedures and tests done that have been authorized. There are options for the future which will be addressed and need to be considered by the individual practice.
- To review and recommend revisions in YOUR process of authorizations
- To identify how to handle denials and appeals
- To set up internal audit processes to review and revise authorization processes
- To consider what the future holds
Areas Covered in the Session:
- Why authorizations from a Payer perspective
- Why authorizations from a Provider perspective
- General and basic procedures related to authorizations
- Reviewing criteria from payers related to their requirements for authorizations
- Management of denials
- Management of the appeal process
- Pre-determination vs. authorization – what are the issues and how to address
- Communicating to the providers on the need for and which procedures require authorizations, support systems in the practice to keep patient flow and care processes in place
- Documentation requirements and how to ensure communication with payer about the need and outcome of procedures performed
- Outsourcing is an option, is it worth it?
- Internal strategies to address payer requirements both current and how to reduce impact, even remove the requirement for authorizations
- Internal metrics on what, how successful and what can be done to improve or reduce issues related to lack of payment for authorizations (or not having authorizations)
- Care plan development and the application to the authorization process
- Future of authorization management – legislative, electronic (AI)
Who Should Attend:
- Office Managers
- Practice Manager
- Finance Manager
- ASC Owners
- Credentialing Manager or Specialists
- Billing Manager
- Mid-Level Providers
- Non Physician Practitioner such Physician Assistants, Nurse Practitioners
- Healthcare Staff
About the Presenter:
Owen Dahl is a principal of Owen Dahl Consulting, in The Woodlands, Texas. He has 53 years of experience in consulting, running a medical billing service and managing medical practices. He also is the contributing author of the popular book Lean Six Sigma for the Medical Practice and the recently published Integration of Behavioral Health Into Medical Homes: A Rapid Implementation Guide. Owen has 53 years of experience in consulting, running a medical billing service and managing medical practices. He speaks on issues related to strategic planning, Lean and Six Sigma, culture, human resource management, revenue cycle among others. Owen was a hospital administrator. He is an adjunct professor at the University of New Orleans. Owen received his Bachelors degree in Hospital Administration at Concordia College, Moorhead, MN and his Master’s from the University of Northern Colorado. He recently achieved his Lean Six Sigma Master Black Belt through Villanova University. He served in the USAF.
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