2025 Updates & Trends in Prior Authorization

Event Materials (Key Required)

Insurance companies continue to complicate the prior authorization process in an effort to manage when procedures should be performed as well as where can they be performed to be most cost efficient. From completing forms to speaking with insurance company representatives, each insurance company has their own process for prior-authorization. They also have different policies on what the pre-requisites and what conservative treatment is required prior to procedures being authorized. In this webinar we will discuss tips on dealing with all of the requirements an insurance company may make and also discuss retro-authorizations, eligibility, and medical necessity.

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 retro-authorizations
• Apply insurance carrier guidelines to be able to meet medical necessity
• Obtain the most accurate prior authorizations for maximum reimbursement

Areas Covered in the Session:

• Overview
  • Eligibility
  • Prior-Authorization
  • Retro-Authorization
  • Medical Necessity
• Eligibility
  • Is the patient’s insurance effective on the date of service?
    • Insurance company
    • Practice management system
    • Clearinghouse
    • Software vendor
• What should you look for?
  • Real time insurance coverage effective and termination dates
  • Ability to batch and “on the fly” verification
  • Plan benefits based on the providers status in the patient’s network
  • Coverage of services and procedures that may be performed
  • Deductibles and copays
• Medicare Coverage
  • HIPAA Act of 1996
    • Electronic transaction code sets approved 270/271
  • HIPAA Eligibility Transaction System (HETS)
  • Medicare carriers offer software on their sites for coverage
  • Effective date
  • Medicare A,B,C,D
  • Medicare Secondary
  • Deductibles
• Operating Rules
• Commercial Insurance
• Example- Eligibility Checklist
  • Patient demographic information
  • Effective/Termination date
  • Network Coverage In/Out
  • Deductible, co-insurance, copay
  • Plan benefits
  • Prior authorization requirements
• Prior-Authorization(Pre-cert)
• Prior-Authorization Requests
• Prior Authorization Links
• Retro-Authorization
• Prior-authorization Checklist
• Criteria Used for Coverage Determination
• Medical Necessity
  • Relationship with procedure or service to patient’s condition
  • Wikipedia definition:
  • Medicare:
• What is an NCD or LCD?
  • National Coverage Determination
    • Nationwide
    • Medicare
  • Local Coverage Determination
    • In absence of NCD
    • Medicare contractors
    • Geographic
• Medicare Coverage Database
• Commercial Carriers
• Insurance Policy Checklist
• Common Denials
  • Denial Codes- CO-50
  • Remark Codes- N115
• State Insurance Commissioners

Suggested Attendees:

• Healthcare CEOs and CFOs
• Billers
• Coders
• Administrators
• Managers
• Supervisors
• Physician
• Non-Physician Providers
• Qualified Healthcare Professionals
• Medical Assistants
• Claims Adjusters

Presenter Biography:

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Additional Information:

System Requirement:

• Internet Speed: Preferably above 1 MBPS
• Headset: Any decent headset and microphone which can be used to hear clearly

For more information, you can reach out to the below contact:
Toll-Free No: 1-302-444-0162
Email: care@skillacquire.com

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Snippet From Our Previous Session