Additional Prior Authorizations For Medicare Are On The Way

Just when you thought your utilization management staff had enough to deal with, Center for Medicare & Medicaid Services (CMS) is adding more to your back-office workload.

Starting July 1, 2020, hospital OPD services will require Prior Authorization for Blepharoplasty, Botulinum toxin injections, Panniculectomy, Rhinoplasty, and Vein ablation. The rules are simple; if your practice does not have Prior Authorization for the procedure, you will not get paid. Prior Authorization is not about giving quality care; it is about saving money. On top of that, in this case, Prior Authorization does not guarantee the payment; it only exempts the claim from a routine audit.

Looking at the existing data, the American Medical Association (AMA) found that 29% of physicians spend at least three days waiting on insurers for a prior authorization response, and 91% reported it resulted in a delay in necessary care.

Lori Intravichit, CEO of Sunlit Cove Healthcare said:

We see more and more physicians and nurses working on prior authorization issues or adding staff to deal with it. This certainly does not reduce healthcare costs.

What’s in it for CMS? 6.5%, to be exact.

It will cost CMS $7.4 million to administer the program to review the 120,000 procedures that are performed each year, with payments of $115,000,000. What that means is that at least 6.5% of all requests must be denied for Medicare to save money.

Spend less time at your desk, and more time with your patients.

Prior Authorization is about cost-savings for CMS, not care. We can help your office save time, money, and a piece of your sanity and obtain prior authorizations without adding additional staff and resources to your office. Contact us or give us a call at (727) 278-3009 to get started.

Sunlit Cove Healthcare Consultants

We provide management and consulting services to help healthcare businesses run efficiently. Navigating the dynamic and complex revenue cycle management is a challenge for many health plans, health care vendors, and providers. Our consulting services are available to assist with your day-to-day operations and provide expertise in growth and change management. We manage all aspects of your enterprise from the development of the revenue cycle management process to the completion of your business cycle.

Related Utilization Management: