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The 2024 Prior Authorization Process For Medical Providers
The document outlines the 2024 prior authorization process for medical providers, highlighting key challenges and regulatory changes, including a new CMS rule aimed at improving data exchange. It emphasizes the importance of medical necessity in determining care, noting the disconnect between insurance payers and healthcare providers. Additionally, it discusses the impact on various roles and workflows in the healthcare system.
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The 2024 Prior Authorization Process For Medical Providers
- 1. Mastering the 2024Prior Authorization Process for Medical Providers PRESENTED BY TONI ELHOMS, CCS, CPC, CPMA, CRC, CEMA, AHIMA-APPROVED ICD-10-CM / PCS TRAINER 1
- 2. Toni Elhoms, CCS,CPC, CPMA, CRC, CEMA, AHIMA Approved ICD-10- CM/PCS Trainer ❑ CEO – Alpha Coding Experts ❑ Podcast Host – Alpha Coding Podcast ❑ National Speaker - Coding, Compliance and Reimbursement SME ❑ Former President of Orlando, Florida AAPC Chapter ❑ Expert Witness ❑ Published Author ❑ Consultant/Educator/Trainer 2
- 3. Agenda High-level overview ofPrior Authorizations and key challenges in 2024 Discuss the role of Medicare Necessity in the PA approval process Explore the regulatory landscape for Prior Authorizations in 2024 Discuss workflows and roles impacted by Prior Authorizations in 2024 Q&A at the end 3
- 4. 2024 Prior Authorizations ❑Prior Authorization (PA) = process by which a physician/QHCP must obtain advanced approval from a health plan BEFORE a specific procedure, service, device, supply, test, or medication is delivered to the patient to qualify for payment coverage ❑ AKA ❑ Preauthorization ❑ Precertification ❑ Prior approval ❑ Prior notification ❑ Prospective review ❑ Prior review 4
- 5. 2024 Prior Authorizations Source:Phoenix Virtual Staff 5
- 6. Medical Necessity ❑ Thereis often a major disconnect between how insurance payers interpret and apply medical necessity rules and how healthcare providers and physicians determine what care/treatment is medically necessary ❑ The disconnect between providers and payers can have systemic consequences for patient care and healthcare organizations if not carefully and strategically addressed ❑ Conflicts of interest considerations with payer cost containment strategies 6
- 7. 2024 Prior Authorizations Source:AMA Prior Authorization Impact - Physician Survey 7
- 8. 2024 Prior Authorizations Source:AMA Prior Authorization Impact - Physician Survey 8
- 9. 2024 Prior Authorizations Source:AMA Prior Authorization Impact - Physician Survey 9
- 10. CMS-0057-F ❑ In 2024CMS introduced a landmark final rule - Interoperability and Prior Authorization (CMS-0057-F) ❑ Applies to Medicare Advantage, state Medicaid and Children’s Health Insurance Program (CHIP- FFS), Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plans on the Federally Facilitated Exchanges ❑ Now required to implement and maintain Health Level 7 (HL7) application programming interfaces (APIs) to improve electronic exchange of data to streamline the PA process 10
- 11. Who is Impacted? Physicians/NPPs/Other Healthcare Providers Revenue Cycle - Coders/Billers/Auditors Scheduling and Case Management Compliance Professionals EMR/PM Vendors 11
- 12. Workflows Impacted Clinical Documentation Templates/Forms Schedulingand Case Management Workflows Coding/Billing/Auditing 12
- 13. Best Practice Tips MedicalNecessity cannot be overstated in clinical documentation Poor documentation and/or code capture can make all the difference in patient care Request a Peer-to-Peer when necessary and come prepared with peer reviewed literature Don’t sleep on notice of material changes, payer coverage policy updates, updates to NCDs and LCDs, formularies 13
- 14.