Eligilibility, Prior Authorization, and Medical Necessity

There are several parts of seeing a patient and receiving payment for professional services.  Eligibility ensures that the patient’s insurance coverage is active on the date of service that the services will be rendered and that their plan covers the services planned.  There are different methods of receiving eligibility information and we are going to discuss these.  Once eligibility is verified, certain procedures require the provider to contact the insurance company to receive prior authorization.  Unfortunately, every insurance company has different requirements, making it difficult to manage.  It is important that offices keep track of the current policies for the insurance companies they work with the most, and ensure these authorizations are performed prior to the service being performed.  Medical necessity is normally reported by  the ICD-10-CM codes.  These codes justify why a procedure or service is performed based on the patient’s condition.  The insurance companies may have policies that define the services they consider medically necessary based on the diagnosis.  If the information on the claim does not meet their guidelines, the claim will be denied.

Insurance companies are requiring that authorization for services be obtained for more services and procedures.  It is also common that employers will change insurance plans to save money on monthly premiums.  This session will walk through how offices can obtain eligibility before the patients are seen to confirm that the insurance information that is available is accurate and the patient is covered for services to be rendered.  Then when the patient is seen, any services or procedures that are ordered may need to be prior authorized for that reimbursement will be received.  The final piece is that the medical necessity requirements for the procedure or service is being met according to insurance company policies and guidelines.  Attendees will benefit from this webinar in that we will discuss all of these aspects of a medical claim that may have to occur before the insurance company even processes it and will reduce the number of claims an office can receive because these steps were not taken.

1. Methods available for eligibility
2. When is the best time to verify eligibility
3. Know when prior authorization is needed
4. Getting authorization for special circumstances
5. What to do when prior authorization has to be changed
6. Why does medical necessity play a role in reimbursement
7. There is never a guarantee of payment