The Hidden Costs of Prior Authorization in Cardiology: A Billing Perspective

 Almost 1 in 8 prior-authorization requests in cardiology billing get denied, which not only hinders practitioners’ revenue cycle management but also patient care. Thus, practitioners need expert help to navigate through such complexities.

Cardiology care often occurs in high-acuity healthcare environments, involving various high cost and high-risk procedures. As a result of this, pre-authorizations for procedures also rise in cardiology billing. Prior authorization (PA) in medical billing is an essential step whereby practitioners acquire advance approval from insurance companies before performing specific procedures, or prescribing medications to confirm medical necessity.

As per industry experts, 48% of total cardiology service procedures are subjected to prior authorization (PA) by Medicare Advantage plans. This can lead to administrative overload for practitioners, as any minor mistakes in obtaining such approvals can hinder their revenue cycle management. Thus, hiring a team of experts becomes necessary for cardiology practitioners.

Everything you need to know about cardiology billing

Cardiology billing involves managing the entire revenue cycle for cardiovascular services. Essentially it involves billing for cardiovascular procedures, covering patient registration, ensuring accurate use of coding (CPT/ICD-10), receiving prior authorizations, submission of claim, denial management, and account receivable follow-up, among others. Some of the common procedures that fall under this billing include complex cardiology procedures for pacemaker insertions, percutaneous coronary interventions (PTCA) among others.

Why are prior-authorizations needed in cardiology billing?

As hinted above, obtaining such approvals in cardio-vascular treatments is a common practice. Some of the reasons as to why this happens will be discussed down below:

High cost: Most cardiology procedures are highly expensive given the involvement of specialized tools and implants among others. Some of the most expensive procedures include cardiac catheterization, coronary angiography, and pacemaker implantation. Through such approval requests, insurers review whether the procedure is medically necessary for the patient. This allows to make sure their financial resources are used effectively.

High risk: Cardiology procedures like imaging services often expose patients to radiation risks. For example, CT scans carry a low but non-zero long-term cancer risk through radiation exposure. Through such approvals, insurance companies can further analyze the medical necessity of the procedure for the patient reviewing medical history of patients, doctor clinical notes among others. This way they potentially help patients from facing such radiation exposure.

Overuse of medical resources: Cardiologists often prescribe advanced cardiac imaging and interventional procedures for their patients more than once or twice. This happens mostly for cardiac MRIs, cardiac CT scans, among others. Through pre-authorizations, insurance companies try to control unnecessary testing and thus ensure sustainable use of medical resources.

Key challenges of preauthorization in cardiology billing

Obtaining prior authorizations in such billing is a very complicated procedure. To begin with, it requires billers to submit detailed clinical notes, previous test results, and even a justification letter to insurance companies. This ensures maximum transparency amongst the parties involved regarding the patients’ medical circumstances. However, organizing such documentation can be time consuming. This can cause administrative overload. Furthermore, often practitioners' notes can have gaps in documenting patients’ medical status. This will also create discrepancies; further making it hard for billers to justify the medical necessity of the procedure prescribed. Not only that, receiving prior authorizations within time makes it trickier. For instance, often patients seeking cardiovascular services like angiograms require instant care, and any delays in receiving such approvals can be detrimental.

Additionally, it also requires billers to conduct frequent follow ups with the insurer, as delays in approval can hinder patient care. They are required frequently to refer to insurer portals and even reach out to insurance companies via calls to make sure the approval request is processed smoothly. Some of the reasons for delays in prior authorizations include, incomplete documentation, inaccurate coding, or some additional clinical information may be requested by the insurer. Thus, regular follow-ups will allow the billers to track the authorization status effectively. For example, billers can submit any missing documents required and resolve issues promptly. This will require much time from practitioners in the absence of an effective billing team, all of which can hinder patient care.

Given all these challenges, it is necessary for cardiologists to partner with an effective team of billers. Such experts can help manage such administrative burden, while practitioners are focused on patient care.

How outsourcing a team of experts can help matter

In medical billing, outsourcing expert help has become a common practice. One of the most crucial reasons is the fact that these external teams are much more cost effective than having an internal team. For example, RCM solution companies like SunKnowledge claim to reduce 80% billing costs for practitioners and charge as low as $7/hour. They even offer a free account manager. This decreases the need for navigating the complex tasks of internal team management, including managing higher salary expectations, and staff training. Apart from that, these experts are updated on payer specific demands for prior authorizations, which allow them to apply for such requests promptly. For example, many RCM solution companies claim to ensure 100% same day submission for prior authorization requests. This makes them a great choice for practitioners to deal with the administrative overload of billing.

Streamline your cardiology billing with the right partner

Obtaining prior authorizations in cardiology billing is a complex procedure, requiring billers to show detailed documentations and conduct regular follow ups. This can increase the administrative overload for practitioners by further hindering patient care. However, outsourcing a team of expert billers can help navigate such complexities further enhancing the practitioner's revenue cycle management.

Are you also looking for some help in obtaining prior authorizations in your cardiology practice? Outsourcing is your best option.