Prior Authorizations are a cost containment strategy that third-party payers leverage to control costs, restrict patient access to services, testing, and medications, and ultimately discourage medical providers from ordering unnecessary medical treatment. Prior authorizations are a major source of headaches for healthcare providers nationwide. Despite the intention to control costs and ensure appropriate care, the prior authorization process has been criticized for its enormous administrative burden, potential delays in necessary medical treatment, and added complexity for healthcare providers. Striking a balance between cost control and efficient patient care remains a major challenge in the healthcare industry. Join us for an insightful 60-minute webinar as we take a deep dive into the complexities of the Prior Authorization process, discuss the pearls and pitfalls, define medical necessity requirements, and demystify the intricacies of obtaining prior authorizations, ensuring a smoother workflow and higher approval outcomes in 2024. Learning Objectives Understand the major Prior Authorization Updates for 2024. Recall medical necessity and its critical role in the Prior Authorization approval process. Identify which insurance payers require Prior Authorizations in 2024. Recall methods for obtaining Prior Authorizations in 2024. Recognize common challenges experienced when obtaining Prior Authorizations. Understand how to escalate and appeal Prior Authorization denials in 2024. Areas Covered Discuss the major Prior Authorization Updates for 2024. Explore the 2024 Prior Authorization requirements for Medicare Advantage Plans. Define medical necessity and its critical role in the Prior Authorization approval process. Explore the regulatory landscape for Prior Authorizations in 2024. Identify which insurance payers require Prior Authorizations in 2024. Discuss methods for obtaining Prior Authorizations in 2024. Review common challenges experienced when obtaining Prior Authorizations. Outline successful strategies to overcome challenges with obtaining Prior Authorizations in 2024. Discuss how to escalate and appeal Prior Authorization denials in 2024. Share best practice compliance tips for Prior Authorizations in 2024. Register Now, https://conferencepanel.com/conference/mastering-the-2024-prior-authorization-process-for-medical-providers

1. Mastering the 2024 Prior
Authorization Process for
Medical Providers
PRESENTED BY
TONI ELHOMS, CCS, CPC, CPMA, CRC, CEMA,
AHIMA-APPROVED ICD-10-CM / PCS TRAINER
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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
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3. Agenda
High-level overview of Prior 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
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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
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5. 2024 Prior Authorizations
Source: Phoenix Virtual Staff
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6. Medical Necessity
❑ There is 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
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7. 2024 Prior Authorizations
Source: AMA Prior Authorization Impact - Physician Survey
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8. 2024 Prior Authorizations
Source: AMA Prior Authorization Impact - Physician Survey
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9. 2024 Prior Authorizations
Source: AMA Prior Authorization Impact - Physician Survey
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10. CMS-0057-F
❑ In 2024 CMS 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
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11. Who is Impacted?
Physicians/NPPs/ Other Healthcare Providers
Revenue Cycle - Coders/Billers/Auditors
Scheduling and Case Management
Compliance Professionals
EMR/PM Vendors
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12. Workflows Impacted
Clinical Documentation
Templates/Forms
Scheduling and Case Management
Workflows
Coding/Billing/Auditing
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13. Best Practice Tips
Medical Necessity 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
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14. Register Now
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