Soft Moss

Getting prior auth is like cooking. It takes time, there's usually some improvisation, and sometimes it doesn't end well. Some tips: 1?? Make recipes. Combine your team's experience to develop consistent recipes for each procedure and health plan so you get more reliable results. 2?? Know how long each recipe takes to complete. Understanding how long each recipe usually takes helps you plan appointments more accurately. Schedule too early and the food won't be ready — you'll need to reschedule. Schedule too late and the food won't be fresh — the patient may get care elsewhere. 3?? Find better recipes. Using better methods and tools can help you "cook" faster and more efficiently. But be careful: like some online recipes, not all tools are effective. ------- Need help with your prior auth cookbook? Let's talk!

Prior auth is like playing a game with an older sibling. It feels like they're just making up rules. What you should know is that each payer actually communicates the rules of their game. One example is medical policies. Many payers publish their medical policies online. They're literally giving you their rubric for medical necessity. In the comments, I'll post links to some of the major payer's policies. One of the biggest innovations in prior auth in the past couple years is organizing your clinical documentation in a way that matches the rubric provided by payers. Generative AI shines at this. The Da Vinci Documentation Templates and Rules (DTR) standard — one of the standards CMS is pushing by 2027 in the upcoming regulation (CMS-0057-F) — aim to tell you what the payer requires from you in real-time. If you have the rubric, you should be able to predict when you're going to get a medical necessity denial. By all means, advocate for the best patient care. But please, don't burn yourself out with a peer-to-peer because you didn't follow the rubric they gave you. Yes, just when it feels like you've got it figured out, the rules may change. If you want to succeed, your choices are to stay on top of the rules or stop playing the game (i.e., stop taking insurance). Ultimately, playing by the rules is going to get you ?? faster response times and ? fewer denials. I led the?prior auth development team at Epic. I'm a freelance prior auth consultant now. I’ve seen the headaches of providers, payers, and tech companies firsthand. I share some of these stories here on LinkedIn. If your organization does prior auth or is building tech to make it easier, let’s chat. I can help with strategy?or provide?hands-on support.

Mistakes in prior authorization can cost your practice thousands in lost revenue. And they happen more easily than you think. In a post last week, I talked about how prior auth staff seem to "just know" what to do. In the next week or two, I'll post about some specific examples from my time at Epic and beyond. Today's focus: choosing the right web portal for prior authorization. Sounds trivial, right? But did you know that payers often delegate parts of their utilization management (UM) process to third parties? (Look up "radiology benefits manager.") The patient may have Cigna, but that doesn't mean you can just go to Cigna's website for all prior auths. Still not too bad. But beware: ?? Delegates can change. ?? Getting it wrong can be expensive. True story: A delegate rep said "we don't do prior auth for that CPT code" and the prior auth specialist thought that meant prior auth wasn't required. But... it actually was — from a different delegate. Months later: claim denial. Big write off. Ouch. Don't lose revenue to the nuances of the prior authorization process. Leverage your team's collective intelligence. I can help.

If you observe a prior auth specialist, you'll see that there are intricacies in how they navigate the process. If you ask them how they know to do what they're doing, they usually say something to the effect of "I just know". This is what I call "collective intelligence" in my latest blog post. How do you make everyone on your prior auth staff instantly "just know" from the moment they are hired? There are fancy ways of re-creating and, in some cases, improving on the human collective intelligence, but there doesn't seem to be simple technology to collect and update intelligence from the staff themselves in a workflow-integrated way. Why not? Have you seen other methods of leveraging collective intelligence, in prior auth or otherwise?

Prior authorization teams have always relied on collective intelligence whether they know it or not. Is your organization making the most of your collective intelligence to reduce denials and increase throughput? Read more: https://lnkd.in/gR3HEF44

Has your state passed prior authorization reform laws in 2024? See which ones have in the link below. https://lnkd.in/g3TimmSX

Soft Moss is a de-stressor as seen here: https://lnkd.in/dptNTyF5

Despite the high visibility of UnitedHealthcare's gold card program, they continue to expand prior authorization requirements in some areas in quieter ways.

This is a great guide to AI in revenue cycle in a fast-changing world!

AMA: Physicians don't believe payers have made meaningful improvements to prior authorization. But why would they?