Prior Authorization Services: Why Insurers Deny or Approve PA Requests
Prior authorization services help healthcare providers get approval for medical services from insurance companies promptly. For pre authorization requests to be approved by the insurer they must fulfill certain Utilization Management (UM) criteria.
These requirements are meant to ensure the services are medically necessary and cost-effective. Prior authorization has certain benefits but it also delays medical care.
PA requirements help:
- Restrict unnecessary utilization of resources
- Ensure healthcare costs are justified
- Prevent delivery of harmful or useless treatments
Based on these objectives, insurers may approve or deny pre authorization requests. To ensure these objectives are met, PA requests are checked against the following utilization management criteria:
- Medical necessity: This requirement helps cancel out unnecessary medical procedures or tests. Often prescriptions that include diagnostic imaging tests, durable medical equipment, and rehabilitation services are scrutinized to see if they are actually medically necessary.
- Cost-effectiveness: This requirement is used to ensure that cheaper medical alternatives are tried out first before prescribing medicines, tests, and procedures that are more expensive. Wheelchairs, prosthetics, MRI scans, or expensive prescription drugs can be denied prior authorization due to cost-effectiveness concerns.
- Admin errors: Administrative mistakes in medical coding, billing, or filling up the form can lead to cancellation or denial of prior authorization requests by insurers. When requests are denied because of such incorrect details they can be resubmitted again with the correct information.
- Insurance coverage guidelines and policies: Medical coverage guidelines and policies may vary based on the insurer. So if the insurer receives a PA request that does not fall under its coverage guidelines, they will reject it. In such cases, the patient may receive complete or partial coverage based on the payer’s policies.
How Sunknowledge’s Prior Authorization Services Ensure UM criteria are met?
To ensure utilization management criteria are met, our healthcare prior authorization services ensure accuracy of medical information and compliance with all UM requirements mainly medical necessity and cost-effectiveness.
Our prior authorization services are supported by PA specialists who are certified, have experience in pre authorization operations, and are regularly trained to keep them updated about guidelines or policy changes.
To learn more, or to try out the 30-day free trial of our pre authorization services, please feel free to reach out to Sunknowledge Services Inc., a HIPAA-compliant healthcare revenue cycle management company with over 18 years of experience in optimizing revenue cycles.
