Strategies for Streamlining Cardiology PriorAuthorizations
For cardiologists, it is common to require prior authorizations for certain services they provide. And it can be nothing less than a puzzle to solve. The reason is insurance companies commonly have stringent policies regarding some cardiology services, like echocardiography and certain complex surgeries. Through prior authorizations, they ensure that these policies are implemented fair and square.
But what is a prior authorization?
It is the process of getting approval from the patient’s insurer before delivering a service. In cardiology procedures, prior authorizations can help:
- Establish medical necessity for the service
- Reduce the risk of denials
- Cut down wait times for the patient, gaining their trust
- Ensure compliance with the payer policies
These benefits can lift your cardiology practice substantially. But it’s important that you understand the intricacies of prior authorizations. In this blog, we will discuss top strategies to streamline PA for your cardiology practice.
Common Cardiology Services That Require Prior Authorizations
As a cardiologist or vascular surgeon, you may want to check the following services for precertification requirements before offering them to your patients:
Diagnostic Services
- Diagnostic catheterization
- Ultrasound
- Echocardiogram or stress echocardiogram
- Nuclear stress test
- Venogram
- Vascular and bilateral lower extremity angiogram
- Arterial, carotid, and venous Doppler
Interventional Treatments
- Cardiovascular stents
- Percutaneous coronary intervention
- Endovenous radiofrequency ablation
- Electrophysiology implants
- Laser ablation
These procedures are highly regulated and hence require PA. The purpose is to ensure that the treatment is rendered only after the medical necessity is established. But this process adds quite an administrative burden to cardiology practice management. This is why most practices outsource prior authorizations to third-party billing companies.
Cardiology Prior Authorization Workflow
The main steps of PA for cardiology practices include the following:
- Eligibility verification: Prior authorization starts with eligibility verification, which involves verifying that the proposed service is backed by the patient’s insurance.
- Documentation: The revenue team collects necessary details like patient information, physical notes, medical records, and diagnostic reports.
- Submitting pre-authorization request: The cardiology practice submits all the documents to the insurer through post or digital means. This submission acts as a request to approve the insurance cover for the procedure in question.
- Following up: The revenue team of the cardiology practice stays in touch with the insurance provider to get information about the request status.
- Getting the decision about authorization: The insurance company denies or approves the request. The approval prompts the commencement of service provision to the patient.
- Managing PA denial: In case of a non-authorization, the revenue team collects more information and rebuilds the request for an appeal.
Common Guidelines From The Payer And Regulatory Bodies
Cardiology practices must comply with specific guidelines to obtain prior authorizations for certain procedures. Most of these guidelines come from regulations established by regulatory authorities and payers.
Payer-Specific Guidelines
These guidelines outline criteria that insurers set for certain cardiology tests and treatment procedures. These guidelines can differ from payer to payer. For this reason, it can be a bit tricky to adhere to these guidelines. However, you can make things convenient for yourself by memorizing some basic steps, such as:
- Learning which cardiology procedures you will need pre-authorization for
- Obtaining all the documents required to prove the medical necessity of the procedure
- Submitting the prior authorization request through the proper channel
- Turnaround time for the approval
- Appealing, in case the request for prior authorization gets rejected
Regulatory Guidelines
These guidelines are standard as they are regulated by central healthcare bodies and the government. So, adhering to these instructions is necessary to ensure your ethical and regulatory compliance. The purpose of these guidelines is to enforce standardization in the prior authorization process at both the practice and insurer end.
Examples of regulatory guidelines include the following:
- Authorization timeliness: Rules around this aspect direct cardiology practices and insurers to work on approvals within pre-established deadlines. These guidelines also specify protocols for procedures requiring urgent approvals.
- Guidelines for medical necessity: These rules explain benchmarks based on which practices and insurers can determine a procedure’s medical necessity.
- Federal and state laws: Some state laws specify rules to limit delays in pre-authorizations.
- Compliance: Some healthcare bodies issue protocols for practices to conduct audits for ensuring that documentation and PA processes are compliant with established standards.
- Denials and Appeals: To appeal denied PAs, practices should follow relevant instructions from the insurer. These instructions typically emphasize reviewing documentation for errors and re-submit the request within a set deadline.
Key Steps To Streamline Cardiology Prior Authorizations
- Review services thoroughly: Instead of determining procedures for pre-authorizations at the last minute, conduct this review well ahead of time.
- Use technology: Use electronic health records (EHRs) to track authorization requests and reduce errors. Also, integrate AI and automation into the areas where you can reduce manual efforts.
- Use standard formats for documentation: Templates and forms are not only easy to fill out but also reduce the risk of errors in documentation. So use them to your advantage.
- Communicate with clarity: Make sure that you can communicate easily with patients and payers. This will help quash delays in authorizations.
- Track your billing performance: Use modern-day analytics to look into your processes and identify problems that cause authorization delays.
- Train your staff: Make sure your billing staff is well-versed in the authorization process.
- Outsource your billing operations: Find an expert RCM provider and hand them over your billing tasks. They will take care of your entire billing work, including prior authorizations.
Final Thoughts
Prior authorizations in cardiology procedures can be tough. But they are a vital part of the
revenue cycle management process. Using the above information, you can overcome
authorization challenges for a streamlined revenue inflow.
However, if you are finding it hard to manage authorizations yourself, you can outsource this job to a billing company. At AltuMED, we offer comprehensive yet flexible billing solutions. This means not only do we offer complete RCM services, but we also allow you to pick any specific service based on your needs. Yes, you can outsource your cardiology prior authorizations to us, and rest assured that you will get great results.
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