Prior-Authorization and Medical Necessity

This webinar will discuss the basics of insurance coverage, eligibility, and prior authorization to assist providers in obtaining this information from insurance companies to help patients understand what their insurance will pay, and what may be their responsibility. Attendees will learn the differences between a patient’s insurance coverage, eligibility, and prior authorization and then be able to apply their knowledge in their office. Most insurance companies offer different plans that cover different services and procedures. Once an office has verified that a patient is eligible for benefits on a particular day, the coverage will determine what the insurance company will pay, and what may be the responsibility of the patient. We will also look at the ins and outs of contacting the insurance company of prior authorization and what to do in the circumstances when the procedures performed change during the surgery.

Learning Objectives:

• Understand the difference between insurance coverage and prior authorization
• Realize the role medical necessity plays in the authorization and reimbursement process
• Learn the importance of eligibility processes before the patient is seen
• Implement an eligibility plan in their office
• Reduce the number of retro-authorizations
• Apply insurance carrier guidelines to be able to meet medical necessities
• Obtain the most accurate prior authorizations for maximum reimbursement
• Understanding the intricacies of Prior Authorization
• Deciphering the workflow of the Prior Authorization process
• What are the implications of Prior Authorization delay
• Trends in the healthcare system
• How to better navigate prior authorization requests

Areas Covered in the Session:

• Insurance Companies websites for prior authorization
• Medicare procedures that require an authorization
• Medical necessity and where can the information be found
• Working with scenarios when what was authorized is not what was done
• Medicare NCD and LCD
• Other ways to find out information about prior authorization
• Eligibility vs. prior authorization
• The use of technology for authorization
• Medicare information related to medical necessity and how different it can be from one geographical location to another
• Denials caused by prior authorization troubles and how to appeal them
• Live Q&A session

Who Should Attend?

• Billers
• Coders
• Administrators
• Managers
• Supervisors
• Physician
• Non-Physician providers
• Qualified Healthcare Professionals
• Surgery Schedulers
• Claims adjusters
• Case Managers
• Physician Assistants
• Revenue Cycle Staff
• Caseworkers
• Nurses
• Reimbursement Staff
• Practice Manager
• Insurance Claim Processors
• Reimbursement Specialist and Staff
• Non-Physician Practitioners