What You Need to Know About the Changing Landscape and the Impact to How Labs Must Submit Claims to Enable Reimbursements

Prior authorization in the medical field is a necessary but flawed process that causes challenges for physicians as well as everyone involved from submission to approval. For those who are unaware, prior authorization is a requirement that a physician obtains approval from a patients health insurance plan to prescribe a specific medication or lab test. Prior authorization is a technique for minimizing costs, wherein benefits are only paid if the medical care has been pre-approved by the insurance company. ¹

While crucial to the healthcare billing process, it has caused a lot of headaches for physicians, patient’s and insurance providers. The broad impact as it relates to the entire medical field is very dramatic. Prior authorization, a practice that is driven by payors, has caused providers to pay over 31 billion dollars a year. ²

Prior authorization requirements effect the medical community as whole, but cause unique challenges to the laboratory space as well. The need for urgency in testing is crucial, especially dealing with expensive tests that are mandatory to get necessary therapies for cancer and other serious diseases. This is why the prior authorization process is so important when it comes to the lab industry and their patients.

Manual processes in prior authorization require physicians and their staff to manage large varieties of documentation that are dependent on the specific tests they are trying to get authorized. This process often results in lost authorizations, decrease in customer satisfaction and low success rates of approval. Prior authorizations success rates for genetic and molecular testing are near impossible to track manually and labs are starting to look to different avenues to help increase revenues and customer satisfaction. Just this past year prior authorization denials increased 311% for lab tests. ²

So how do labs improve this process? Recently XiFin RPM 9 has integrated with PriorAuthNow to help solve this challenge for laboratories by providing a time and money-saving automated process that most organizations lack. To get more information on how our systems’ prior authorization process works view our webinar:

Sources:

1. Gasbarro, R., Dr. (2015, 4 6). My pharmacist says he needs “prior authorization” — what’s that all about? Retrieved June 20, 2018, from Consumeraffairs.com website: https://www.consumeraffairs.com/news/ my-pharmacist-says-he-needs-prior-authorization-whats-that-all-about-040615.html

2. Fetter, K. (2018, May). Prior Authorization of Molecular and Genetic Tests. Paper presented at Executive War College, New Orleans, LA.