EPISODE SUMMARY
Prior authorization (PA) is the boss level of the Eligibility & Benefits domain, the giant locked door that stands between you and getting paid. This week, Jeremy is diving deep into the controversial world of prior authorizations, debunking the persistent myth of the "retro auth" and breaking down exactly how to conquer this gatekeeper of revenue.
We walk you through the three crucial hurdles: Identification, ensuring you know the requirements before the patient walks in; Request, mastering the art of over-communicating medical necessity to avoid the "delay loop" ; and the Outcome—including how to sidestep the exhausting peer-to-peer review trap.
We also zoom out to the massive national conversation happening right now—patient access vs. cost containment—and discuss the "gold carding" trend that could revolutionize how good providers play the game. Learn the two essential tools you need to turn PA chaos into efficiency and ensure your hard work translates into deposits, not denials.
It's time to build a bulletproof process and win The Claim Game as it's played today.
KEYWORDS
Prior Authorization, Revenue Cycle Management, RCM, Insurance Billing, Claim Denials, Medical Necessity, Retro Authorization, Gold Carding, Private Practice, Practice Management, The Claim Game
TAKEAWAYS
Anticipatory Anxiety is Real: Prior authorization is often the most anxiety-inducing step in RCM, and for good reason—missing this step means you get paid $0 for the work.
Identify Early: Prior authorization is a permission slip that must be secured before the service is rendered. Use the intake call and your E&B check to identify if an auth is required for the specific CPT code or service.
Over-Communicate Medical Necessity: Avoid the time-sucking peer-to-peer review trap by making your initial submission bulletproof. Use the payer’s language: detail specific symptoms, measurable goals, and evidence-based treatment.
Retro-Auth is a Myth: Do not build your practice on the "hail Mary pass" of hoping for a retroactive authorization. The best strategy is pre-authorization. If the denial is due to your administrative error, you will usually have to eat the cost.
Track the Count, Don't Blow the Meter: Authorization numbers are not a one-stop gate; they are a meter. Use a countdown mechanism (like one in your EHR) to flag when you hit session eight out of ten. This prevents revenue loss and, most importantly, avoids disrupting your client's necessary care.
Essential Tools for Success: You need two pieces of equipment: a dedicated Prior Authorization Checklist(tracking dates, reference number, stipulations, and expiration) and an updated Insurance Contact Reference List with a tab specifically for authorization requirements.
CHAPTERS
00:00 Introduction: Entering the Prior Authorization Gate
04:03 The Three Hurdles of Prior Authorization
11:15 Access vs. Cost: The Prior Authorization Battle
16:01 The Myth of Retro Authorization
18:11 The Tools You Need to Master Prior Authorization
20:46 Case Study: The Importance of Tracking Authorizations
22:53 Conclusion: Winning the Prior Authorization Game
RESOURCES
Today Sponsors: Blueprint
Learn More About The Claim Game: Visitpracticesol.com/podcast
The Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visitingThe Hourglass Learning Hub.
Our Blog: Explore years of educational articles on billing and practice management atPractice Solutions Blog.
Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.
Images: Prior Authorization Checklist, Insurance Contact Reference List
