The Discussion Continues: Is Prior Authorization Criterion Doing More Harm than Good?

COVID-19 pandemic has changed healthcare industry’s dynamics. The impact might be temporary in some aspects while it can also lead to permanent changes in some situations.

Many changes were suggested to cater the overflowing COVID-19 positive cases. CMS even recommended delaying the nonessential medical procedures to curb down the virus exposure. This certainly was a brave decision as it protected the health of physicians, patients, and medical billing services workers but drag down their financial situation as well.

The prior authorization rule is also under fire for the same reason. Many insurance companies and Medicare payment models are waiving off the prior authorization restriction for diagnostic or surgical procedures for coronavirus.

However, there are many others, which require the pre-authorization segment filled in the claims. Even when the physicians obtain prior authorization, the claim might end up being denied.

Why Prior Authorization is Necessary?

Prior authorization is particularly required for expensive or new medical procedures. If insurance companies don’t pay up for the rendered services or don't prior authorize for the service, medical billing companies will be compelled to ask from the patients, which ultimately will lead to the complicated and frustrating revenue-generating process.

Getting Authorizations Needs Investment

Getting authorizations is not that simple as one thinks. Physicians have to bear extra costs for that.

Healthcare costs are already getting out of hand as physicians have to maintain quality healthcare. In these drastic times, when reimbursements and payment models are failing to compensate physicians’ revenue problems, prior authorization is a clause that needs relaxation.

Why Prior Authorization is a Problem, Especially Now?

The prior authorization criteria from the insurance companies give more power to insurers rather than physicians and patients. Although, it is physicians, who are spending dimes for the authorization process; and with denial of the claim, the return payment becomes zero.

On average, medical billing companies spend at least twenty-seven minutes and almost eleven dollars on each authorization action. Every time, having to consult insurers, physicians get the idea that a third party is dictating the healthcare service. 

Moreover, with more medical procedures requiring prior authorization, the more burden physicians will have to bear.

It is not to be blamed upon insurance companies for such strict rules. It is the US healthcare industry whose complex structure is weighing down all stakeholders, be it, patients, medical practitioners, medical billing services, and insurers.

Coronavirus has adverse effects on the healthcare industry. But it certainly is reveling the problematic areas.

The Counter Action

Some insurance companies are resolving this issue themselves by suspending referrals and prior authorization conditions and requesting notification within a day of any inpatient and outpatient medical service. There are, however, some exclusive cases such as, for transplant and genetic cases.

This service applies to all areas of physicians, even if they don’t belong to a network. It will not only reduce administrative burden over medical billing and coding services but also free up resources, which are consumed up during the delayed billing services.

Some states are working to empower patients and physicians, but the problem is that each state is working on its own, without any collective effort. Therefore, the confusion arises about the after-effects or long terms prerequisites of the COVID -19 counter-strategy.

The authorities say that it is in the best interest of the healthcare industry to continue the practice of prior authorization to avoid surprise medical bills. Popular opinion is that authorities might not know how surprise bills will be unfolded in the future.

The uncertainty and ambiguity disguised in temporary and permanent changes might find solace in technology incorporation.

Prior authorization generally consists of three steps:

•        ICD-10 codes incorporation
•        Automated data submission
•       Retrieval data process

With technology, these steps can be a lot smoother than before. The per authorization cost will be reduced, and of course, time consumption will also be minimum.

Even if the changes prolong, physicians and medical billing companies can enjoy a relaxed working environment. Prior authorization is surely an administrative burden but it encompasses lots of financial benefits. Healthcare professionals need to understand the requirement and adopt methods to make it a primary billing function.

There are opportunities to improve the system, and this time, we may be able to realize what’s best for all stakeholders.

Want to Leverage MIPS 2020? Start Planning Today!

Coronavirus has struck all, but the healthcare industry is under its wrath the most. With double the power, physicians, medical billing outsourcing companies, and MIPS Qualified Registries are working together to undermine the effect.

MIPS 2019 performance year is behind our back, and now it’s time for 2020. Although given circumstances are tough, the planning for MIPS 2020 will get fruitful results in terms of revenue.

Physicians! Bear in mind that with each performance year, requirements change.

• Payment adjustment will be 9% in 2020.

• 45 MIPS points are required to stay penalty-free.

• An exceptional performance bonus will be awarded at 85 points.

The reporting burden is great, but, we can’t afford to stay idle. You are busy dealing with COVID cases and risking your life. We suggest don’t risk your future revenue with the current situation.

Here is a guide to get you through the MIPS 2020 details. MIPS reporting services can take notes and get started.

Check Your Eligibility Status. Review if you’re required to Report Data?

CMS has updated the eligibility tool. Now, physicians or MIPS Qualified Registries can check on their behalf that if they can report data or they will have to opt-in.

Even ineligible clinicians can voluntarily participate in MIPS.

Enter your NPI – National Provider Identification number into the tool to get updates about:

• The eligibility status

• Qualifying Alternative Payment Model (APM, (QP) or a Partial QP participation status

• If the physician is required to opt-in

• The special status designation, For Instance, Small Practice, Ambulatory Surgery Center (ASC)-based, Hospital-based, etc.

If a physician has switched places, checking the latest eligibility status is necessary.

Which Reporting Option to Choose: Individual or Group Participation?

Physicians can report data either individually or in a group. If chosen to report via a group, two or more clinicians can report via the same Tax Identification Number (TIN). All the participants of the group will get the same points in the end.

Group participation, of course, has some advantages. For Instance, Resources and time can be saved as it allows physicians a single MIPS submission on behalf of everybody.

• Group participants only have to report data for a similar set of patients.

• With more physicians on board, there are more chances to accurately submit data.

• However, there is a condition that at least 50% of participants should work upon the same activity for ninety days in order to report for Improvement Activities (IA).

Design Your Reporting Goals

Either you are submitting data via MIPS Qualified Registry or any other MIPS submission method, it's important to set goals beforehand. It gives time to analyze, and reflect the collected data for maximum revenue.

A Little Overview of MIPS Quality Measures

Quality

This category has a total of 45 points.

• Report 6 Quality measures, with at least 1 measure Outcome measure or a High Priority measure

• Reported data should comply with data completeness constraint, otherwise, the physician will receive 0 points. Small medical practices can earn 3 points for this.

• To score high, report each measure for 70% of the eligible patients.

Promoting Interoperability (PI)

This category has a total of 25 points.

• Data should be reported for 90 consecutive days.

• The use of a 2015 certified Electronic Health Record (EHR) is required.

• For extreme and uncontrollable situations, CMS weighs this category to 0 and credits in the quality category.

Improvement Activities (IA)

This category has a total of 15 points.

• Total data for 90 days is required.

• Groups with 16 or more clinicians: Attest to 2 high-weighted IAs or 1 high-weighted and 2 medium-weighted IAs or 4 medium-weighted IA measures

• Individual clinicians and groups with 15 or fewer clinicians: Attest to 1 high-weighted IA or 2 medium-weighted IA measures

Cost

This category has a total of 15 points.

There is no need to submit data for this category. CMS will itself calculate the performance based on the Medicare claim data.

Instructions for Small Medical Practices

• Report 6 Quality measures on 1 eligible patient each with at least 1 measure should be an Outcome or High Priority measure
• Submit 1 High-weighted or 2 Medium-weighted Improvement Activities

QPP MIPS is a MIPS Qualified Registry ready to implement tried and tested strategies to increase physicians' score in MIPS performance. Whether you need assistance in submitting data to CMS or a full-proof plan to stay penalty-free, we got you covered in every need.