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How ICD-10 Impacts Prior Authorizations

Author: Outsource Strategies International
by Outsource Strategies International
Posted: Oct 22, 2015
prior authorization

Once a patient is scheduled for appointment, insurance verification and authorization is imperative to reduce claim denials and increase revenue. Pre-authorization is an authorization that a health insurance or plan requires their beneficiaries to obtain before receiving certain services. Obtaining proper pre-authorization will help providers ensure prompt payment and reduce write-offs. As provider organizations are moving towards the ICD-10 implementation programs, they need to pay more attention to their prior authorization process. As cash flow disruptions are predicted for the coming ICD-10 transition, providers may face serious loss for making even easily avoidable mistakes. Let’s take a detailed look into ICD-10 impact on pre-authorization and how to address it.

Here are the major areas where providers face challenges to obtain prior approval under ICD-10.

Diagnosis Code Submission - Submitting diagnosis codes with prior authorization requests is crucial to obtain approval from the carrier. The increase in the number of diagnosis codes in ICD-10 present a challenge to providers. They must use the most specific codes for prior authorization requests.

Procedural Code Submission - For timely approval of prior authorizations, the ICD-10 codes submitted should match the procedure codes requested. If the codes are mapped incorrectly, it may lead to denials and non-payment.

New Procedures - There may be new procedures that require prior authorizations with ICD-10. This will increase the volume of pre-authorization submissions. Providers will need to handle this efficiently.

Authorization Delays - The information provided in the pre-authorization forms may not be sufficient for carriers owing to the existing manual process. They will ask providers for additional information in order to approve the request. This will cause delay in payment.

Patient Care - The authorization delays and increase in the number of codes is likely to impose excessive pressure on providers, who may find it very difficult to devote time to patient care.

Prior authorization is an important part of the provider-payer-patient cycle and it requires a streamlined approach to make this process more efficient with ICD-10. Here are some effective solutions for that.

  • The physician has to write a letter to the carrier for obtaining prior approval. This would take weeks to months to obtain. This means, providers must complete all ICD-10 training and testing weeks before the implementation date.
  • Physicians may have to change the way they document the pre-authorization request to provide the granular details required by the new ICD-10 codes. They will have to know the ICD-10 codes really well so that they can provide the required information to their office staff preparing the pre-authorization letter. It is important to review all templates and note where additional details will be required to provide appropriate documentation.
  • Provide training to the medical coding staff regarding how to choose the most appropriate ICD-10 codes.

Consider obtaining support from reliable insurance verification and authorization services, because this will help enhance efficiency with trained professionals assisting providers with their pre-authorization requests to carriers, obtaining approval and filing appeals in case of denials.

About the Author

OSI is a leading healthcare BPO company based in Tulsa, Oklahoma, focused on providing reliable medical billing and coding services.

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Author: Outsource Strategies International

Outsource Strategies International

United States

Member since: Apr 12, 2015
Published articles: 16

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