Gastroenterology clinic focuses on providing outstanding patient care with the most effective Gastroenterology services. Prior Authorization plays a crucial part in Gastroenterology Billing as most often the medical necessity of the medical procedure is evaluated by the insurance company to ensure payment of the claim. Prior Authorization and Insurance Eligibility Verification Services goes hand in hand when the medical specialty is Gastroenterology as many insurance companies have varied rules and policies which is mostly tied to the final reimbursement of the claim. Read below to understand Prior Authorization in Gastroenterology and the process involved:
Prior Authorization Requisition Process and Timeline:
- Gastroenterology often requires the determination of medical necessity and timely authorization can reduce denials and increase revenue.
- Best practice would be to obtain authorization 15 days prior to the appointment date to avoid rescheduling or canceling the patient appointment for lack of authorization from insurance company.
- Medical Billing and Coding team have to note that majority of insurances have 15-day timeframes to process & approve prior authorization. Abiding by this timeline will benefit all parties involved such as the patient, physician and also the billing process.
- For EGD procedures patient should be in medication at least 90 days before having the procedure this protocol in fact can cause delays and rejections in authorization approval.
- Upon receiving authorization approval, e-care team will update the Authorization number in the software with a valid date along with any deductible remaining and copay to collect.
- Diagnosis Code plays a major role in authorization requirements, therefore having quality coding is mandatory.
Prior Authorization Process Payer Specification:
- Authorization requirements always depend on insurance type and patient plans.
- Authorization requests for EGD, Colonoscopy, & sigmoidoscopy are initiated at the Ambulatory surgical center setting and outpatient setting as applicable
- There are lists of procedures for EGD and Colon but some insurance will not accept multiple codes in the authorization request, as only one procedure can be requested as per the insurance guidelines. In such case, it is advisable to confirm with the insurance company on the possibilities to change the procedure with same authorization number after the service has been performed.
- Most insurance do not require prior authorization for Colonoscopy screening except for diagnostic service which always depends on the patient’s health and diagnosis.
- Medicare and Medicare supplements do not require authorization when service is done in ASC and outpatient settings. However, authorization requests are submitted for Medicare HMO, advantage, and replacement plans.
- In case the authorization for EGD and Colon is denied due to not medically necessary, a peer-to-peer review with the doctor and nurse reviewer can be scheduled and processed accordingly.
- Submission of an appeal or reconsideration for authorization denial with documents that support the procedure is possible in most cases.
To know more about Gastroenterology Prior Authorization process and for experienced partner reach out to e-care at 1-813-666-0028 or log on to Prior Authorization Process | e-care India (ecareindia.com)