Prior Authorization Services
Prior Authorization is one of the most misunderstood functions associated with managing the medical benefits of self-insured employer groups. Many providers view this process as a barrier to their ability to treat the patient, or a way of delaying treatment. In actuality, when managed care was just beginning, prior authorization was a means of predicting the cost of care provided to the employer group’s membership each month.
Integrated Healthcare Management uses the prior authorization process to facilitate our knowledge of the members healthcare needs, and to alert our medical professionals when intervention with the patient maybe necessary.
Prior Authorization allows us to know when a patient is admitted so that our nurses might interact with the hospital to facilitate discharge planning, and case management after discharge which guards against readmission.
Prior Authorization is performed using nationally recognized criteria. Requests for medical services are measured against these criteria and the Integrated Healthcare Management Medical Director determines if the requested services are justified based upon the supporting documentation submitted by the requesting provider. If there is a disagreement, the Integrated Healthcare Management Medical Director speaks directly with the requesting provider to ensure the member receives the appropriate service. This process protects the member from the receipt of unnecessary care and ensures that the provider is compensated correctly. The Integrated Healthcare Management review process takes 24 hours or less to complete, so care is not delayed.
An efficient prior authorization process, in addition to protecting the patient, saves the employer group 10% on the annual cost of outpatient medical services.