Optimizing Front End Revenue Cycle Management: The Power of Prior Authorization

Patient Access Solutions and Insurance Coverage

Patient access solutions are tools or services that can streamline the healthcare journey, simplifying appointment scheduling, insurance coverage checks, and post-visit payments. Confirming insurance coverage is a step of the healthcare journey that is critical to medical billing. Pre-certification, also known as prior authorization, is the process where a healthcare provider obtains approval from a patient's insurance company to provide a proposed service. This ensures that the insurance company will cover the costs of the service, saving both the patient and the provider from unforeseen expenses. There are two steps in determining eligibility:

Patient Eligibility Verification: This step confirms whether a patient has valid insurance coverage. It typically includes checking the patient's enrollment status with the insurance carrier, verifying the patient's demographic details, and confirming the effective dates of the patient's coverage.

Insurance Eligibility Verification: This process goes a step further by determining the details of a patient's insurance coverage. It involves verifying which healthcare services are covered under the patient's insurance plan, and to what extent. This can include checking for any pre-existing condition clauses, co-payments, deductibles, out-of-pocket maximums, and any other limitations or exclusions in the patient's policy. It provides a clearer picture of what services the insurance will pay for, and what costs might be the patient's responsibility.

The Importance to the Billing Cycle

Consider a scenario where a patient needs an advanced medical imaging procedure, such as an MRI. This procedure is quite expensive, and it's not always fully covered by insurance without a full prior authorization. The provider performs the scan only to discover later that the insurance company refuses to cover the cost. The patient is now left with an enormous bill that they are unable or unwilling to pay out-of-pocket, leading to lost revenue for the provider and an unexpected financial burden for the patient.

Streamlining the Revenue Cycle

A proactive approach to prior authorization and insurance eligibility verification can prevent such scenarios, reducing claim denials and improving the overall efficiency of the billing cycle. It also enhances patient satisfaction—after all, nobody likes surprise bills. The result is a win-win situation: healthcare providers can ensure they receive payment for their services, and patients are more satisfied as they can better plan for healthcare expenses.

Having the Right Tools

Patient access solutions, such as pMD’s pDemographics service, can automate these critical tasks, which help administrators and practice managers reduce manual labor and minimize billing errors. Working with an effective medical billing partner that can optimize these processes will benefit both the providers and the patients.

How pMD® Can Help

Here at pMD®, our mission is to streamline and optimize as many areas of the patient care episode and the revenue cycle as possible. Through our advanced, end-to-end practice management and revenue cycle solutions, we’re able to help practices consolidate vendors, reduce costs, streamline workflows, improve patient care and satisfaction, and collect your maximum reimbursement quicker.

Not sure what a vendor could do to improve your behavioral health billing? Contact pMD® for a no-commitment financial impact analysis by our team of healthcare RCM experts free of charge!

To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealth, and secure communication software and services, please contact pMD.

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