Understanding the prior authorization changes in MA final rule

The world of healthcare is in a constant state of flux, and as we venture into 2024, pivotal changes in Medicare Advantage (MA) and Part D regulations are poised to reshape the landscape. The 2024 MA and Part D Final Rule, recently unveiled by the Centers for Medicare & Medicaid Services (CMS), shines a spotlight on critical areas such as marketing oversight, prescription drugs, and prior authorization processes. While the entire spectrum of changes is significant, the spotlight particularly falls on prior authorization reform—a long-awaited advancement that has garnered immense attention from providers and healthcare stakeholders alike. 

Unveiling the Burdens of Prior Authorization 

Prior authorization has been an enduring conundrum for healthcare providers, imposing substantial burdens and barriers to timely patient care. The urgency for reform has been underscored by data from the American Medical Association (AMA), revealing that physicians navigate a labyrinth of an average of 41 prior authorizations each week, collectively dedicating a staggering two business days to these processes. 

The real impact of these authorization demands is further felt by patients, with a staggering 93 percent of physicians reporting that their patients encounter delays in accessing necessary treatments or services due to the time-consuming prior authorization requisites. In the wake of these delays, patients may even forsake treatment, raising concerns about their well-being. 

The Medical Group Management Association (MGMA) has cast a spotlight on prior authorizations, labeling them as the top regulatory burden for medical practices in recent years. In fact, last year itself in 2022 alone, nearly 89 percent of practices were compelled to allocate resources exclusively to tackle the challenges of prior authorizations. This unprecedented shift has led to widespread changes in practice dynamics, indicating the imperative nature of prior authorization reform. 

Revolutionizing the Landscape: MA Prior Authorization Changes 

The 2024 MA and Part D Final Rule introduces pivotal reforms in the prior authorization sphere, fostering a more streamlined and efficient process while safeguarding patient access to essential care. These reform measures encompass several key facets: 

• Ensuring Parity with Traditional Medicare – In a bid to ensure that Medicare Advantage beneficiaries enjoy equitable access to care, the final rule necessitates that Medicare Advantage plans adhere to national coverage determinations, local coverage determinations, and the broader coverage and benefit conditions established in traditional Medicare regulations. This move serves to bridge the gap and fortify the continuity of care for beneficiaries. 
• Streamlining Prior Authorization – CMS has embarked on a journey to streamline the prior authorization process, redrawing the boundaries of its application. Health plans will now only employ prior authorization to ascertain the presence of a diagnosis or other medical criteria, ensuring the medical necessity of specific treatments or services. 

• Transition Period and Continuity of Care – To facilitate seamless transitions in care, coordinated care plans are mandated to provide beneficiaries with a robust 90-day transition window. During this period, beneficiaries undergoing treatment and migrating to a new Medicare Advantage plan are shielded from prior authorization demands, ensuring the continuity of their active treatment. 
• Annual Utilization Management Review – The final rule introduces an annual review of utilization management policies for all Medicare Advantage plans, aligning these policies with the coverage guidelines established under traditional Medicare. This strategic alignment aims to enhance consistency and guarantee that beneficiaries receive consistent and comprehensive care across the Medicare Advantage spectrum. 
• Validity of Prior Authorization Approvals – Emphasizing the importance of care continuity, the final rule enforces that prior authorization approvals remain valid for the duration of medical necessity, guided by relevant coverage criteria, a patient’s medical history, and the provider’s expert recommendations. 

In essence, these modifications signify a concerted effort to strike a balance between ensuring beneficiaries’ access to essential care and streamlining prior authorization procedures, you surely need an expert to manage the prior auth confusion. With the constant evolving regulations and changing rules, an expert can not only help you with all your prior auth confusion but assist in managing it seamless. 

Sunknowledge – the conclusion for seamless prior authorization: 

Closing all your prior authorization gaps are closed efficiently, Sunknowledge today is a decade old authorization solution for many leading names in the industry. Improving your clinical validity of coverage criteria, increasing transparency of health plans’ prior authorization processes and reducing disruptions in prior authorization requirements, Sunknowledge further ensures an increase in authorization rate by 1.5 – 2x. 

 Reducing all your administrative burdens and harmonize Medicare Advantage regulations with those under traditional Medicare, Sunknowledge expert streamlined processes, and improved patient access to essential care in no time. With 100 % authorization submission on the same day and 99.9 % accuracy rate, the expert further guarantees highest productivity across the industry. 

So if you are looking for expert solution to manage the complex nature of prior authorization or pre certification, call Sunknowledge now! 

How to cope with the constant prior authorization dilemma

Managing prior authorization has always been a troubled affair. Though the process was solely for improving patient health and providing the right treatment solution at a cost effective rate, for ages it has not only created burned out but has also been the reason for many patient health deteriorations. 

In fact, for years and till today the process of prior authorization in the healthcare industry is a topic of concern for both patients and healthcare providers  

Few prior authorization concerns are- 

• Narrowing Payable Diagnosis Codes: with the constant change in codes, it often becomes difficult for many to ensure the accurate modifier and codes at times. as a report in Becker’s ASC Review highlights the increasing difficulty in obtaining preauthorization for knee osteoarthritis surgeries. Insurance companies are narrowing the payable diagnosis codes, requiring orthopedic surgeons to provide specific and detailed diagnoses for knee osteoarthritis. Simply stating “knee pain” is often insufficient for preauthorization. Patients must meet specific criteria to receive an osteoarthritis diagnosis, making it more challenging for surgeons to get reimbursement for necessary procedures. 

• Inefficiency and Lack of Transparency: Health insurance companies frequently require prior authorization for medications, durable medical equipment (DME), and medical services. Unfortunately, prior authorization policies are fraught with inefficiency and a lack of transparency, leading to delays in patient care. According to the American Medical Association (AMA), physicians often have to wait several days or even weeks for prior authorizations, impacting both patient outcomes and the efficiency of physician practices. 
  
• Increased Administrative Burden: Healthcare providers must handle the administrative burden associated with prior authorization, which can be time-consuming and costly. The Medical Group Management Association (MGMA) conducted a poll that revealed a significant increase in prior authorization requests and other documentation demands from health plans. This surge in paperwork puts additional strain on healthcare organizations, diverting resources from patient care. 
  
• Elaborate Documentation Requirements: Insurance companies often require pre-certification for various medical services, procedures, medications, and medical devices. To obtain reimbursement, physicians must submit extensive documentation proving the medical necessity of the prescribed services or drugs. This elaborate process can lead to delays in treatment, impacting patient outcomes and causing frustration for both patients and providers. 
  
• Varied Preauthorization Policies: Each insurance company has its own unique preauthorization policies, which can vary significantly. This lack of standardization adds to the complexity of the prior authorization process, making it difficult for healthcare providers to navigate the requirements of different insurers. This variation can lead to confusion and potential delays in patient care. 

With all these changes and confusion, it often becomes difficult for many to stay updated and maintain a profitable scenario. This is also why where many today find outsourcing to be a convenient and cost-effective solution to lessen all the authorization woes. 

Sunknowledge – unclog your pre authorization troubles: 

 As the healthcare industry continues to grapple with these challenges, understanding the prior authorization needs and a growing need for streamlined and efficient prior authorization processes Sunknowledge ensures timely access to necessary medical treatments and services for patients. Closing all your authorization gaps efficiently, Sunknowledge authorization specialist not only further guarantees- 

100% authorization submission on the same day 

90% authorization approval rate and an increase in the authorization rate by 1.5-2x. 

Providing end-to-end PA support including Re-Authorization and Dr.’s Office Follow-ups, with full proficiency in working on multiple software platforms as well as the client’s proprietary software or platform, Sunknowledge offers the fastest turnaround time in the industry where regular requests are completed in 24 Hrs. max & STAT requests in under 15 mins. 

So if your prior authorization trouble is keeping you awake at night? Call Sunknowledge and know how the expert can help in changing your authorization strategy for better results. 

How to deal with your complex prior authorization, preauthorization or pre certification

Prior authorization, preauthorization or pre certification has always been one of the daunting tasks in medical billing. It is mainly done to get approval or pre-certification for medication or treatment before being carried out to ensure it is the best solution to the health problems for the patient and if it is covered by the insurance company.  

It is no secret that handling pre-certification is one of the most cumbersome and time-consuming responsibilities for all and also one of the leading causes of frequent burnout. In fact, today 76% of providers are looking for cost effective and convenient solutions to resolve the issues of the pre auth burdens and so Sunknowledge fits in. Here to deliver efficient authorization solutions for all your pre-certification transactions, Sunknowledge for the past 15 + years is known for outstanding support solutions for all. 

Sunknowledge – tackle all your pre authorization ups and downs: 

Assisting various hospitals, outpatient facilities, and physician practices, Sunknowledge has been catering to the complex prior authorization services needs for many leading names in the industry. From obtaining insurance authorization for procedures and services that necessitate prior approval, Sunknowledge not only saves your precious time but with constant follow up further reduces the difficulties of dealing with insurance providers for all. Freeing up staff to concentrate on primary tasks and securing maximum reimbursement, partnering with Sunknowledge as your pre-authorization company can help you be confident that all aspects of the pre-certification process will be handled effectively.  

With dedicated pre-authorization specialists collaborating for better authorization transactions, the expert further ensures: 

• Claims for treatments or services requiring preauthorization are submitted promptly  
• All payer criteria are met before submitting a pre-authorization request  
• 100% authorization submission on the same day 
• Offering customized status updates  

• Decreased paperwork and errors rate, as with the right checks and balances we guarantee 99.9% accuracy 
• Lowered insurance write-offs and denials rate 
• Fast pre-certification turnaround time  
• Increased focus on patient care by 50%  
• 80 % reduction in operational expenses and elimination of unnecessary expenses 

• No long-term annual contracts  

So if you are looking for a professional expert to handle the authorization dilemma and looking for the best solution you know where to call. 

To discover more about our pre-authorization solutions, call Sunknowledge expert over a ‘no commitment call’ now. 

How an operational extension for your Prior Auth process can help

Prior authorization (PA) is a crucial step in the healthcare reimbursement process. Designed to ensure that patients receive the best and cost-effective treatments while having controlled healthcare spending, managing authorization services can be a real challenge. Leading to delays in patient care and increased administrative costs, prior authorization comes with many crises. Thus today it is best to have experienced support to manage the complex affair, plus having operational support taking care of all your pre auth affair further reduces your expenses as well.  

Benefits of partnering with a professional for managing complex prior auth services: 

Streamlined Workflow and Increased Efficiency – An operational extension for prior authorization services saves time, money and resources effort by streamlining workflows, automating manual tasks, and minimizing human error. As a result, providers can expect reduced wait times, fewer denials, and improved cash flow. 

in fact, this further enables healthcare providers to not only focus on the other core functions, such as providing quality patient care and business expansion while the operational extension takes care of all the tedious and time-consuming aspects of the authorization process.  

Improved Compliance and Reduced Risk – It is no secret that Healthcare regulations are constantly changing and making it difficult for providers to keep up with the latest requirements. However, a support from prior auth expert not only helps your organization maintain compliance with these ever-evolving regulations but also reduces the risk of non-compliance penalties and costly audits. In addition, the Prior Auth Consultant further ensures that prior authorizations are submitted accurately and on time in order to prevent denials and appeals reducing financial risks for your practice. 

Access to Expertise and Technology – Outsourcing prior authorization services allows healthcare providers to tap into a wealth of expertise, technology and software that may not be available in-house. Here having a Prior Auth Specialist and a dedicated team of experts who are well-versed in the intricacies of the prior authorization process can quickly adapt to changing regulations, automate and optimize the process in no time, leading to faster turnaround times and increased accuracy. 

Aids in Scalability and Flexibility – When the organization grows, so does the need for efficient and effective prior authorization services. Assistance from the right Preauthorization can provide you with the required help in case of the scalability and flexibility needed to accommodate the rising fluctuations in volume while ensuring that your organization is always equipped to handle the demands of the prior authorization process. 

Cost-Savings – One of the primary benefits of using expert prior auth professionals is the possibility of significant cost savings. By outsourcing these tasks, a provider can not only reduce the overhead expenses associated with hiring, training, and retaining in-house staff dedicated to prior authorization but further help in allocating resources more efficiently. In fact, giving you additional time in focusing on core competencies, partnering with an operational extension improves the overall quality of patient care. 

Sunknowledge: The ideal Operational Extension for Your Prior Authorization Services support: 

Being a leading RCM offering a comprehensive solution that combines advanced technology, experienced professionals, and proven processes to save time and money for healthcare providers, Sunknowledge for the last 15+ years is known for offering state of art prior authorization solutions for many leading names in the industry. 

 Focusing on streamlining workflows, improving compliance, and enhancing data security, Sunknowledge has become the one stop destination for anyone looking to optimize their prior authorization process. 

What makes Sunknowlede unique? 

Being committed to providing exceptional authorization solutions, the expert ensures a dedicated account manager 24*7 for all kinds of assistance. Offering customized solutions tailored to unique needs, offering a level of service that is unmatched in the industry, by choosing Sunknowledge as your operational extension for prior authorization services, you can be confident that your organization is in the best possible hands. As we are here to help you focus on what matters most in patient care while we deal with the complex authorization affair. 

How to Improve Revenue with a Powerful Prior Authorization Stance

It is true that challenges with prior authorization are many! It poses a serious threat and an administrative burden for the managed care organizations, patients as well as the physician offices. It delays the needed care.

The biggest pain with prior authorization is with the administrative process incurring a lot of time and affects healthcare/ provider workflow. Sometimes when a patient sees their physician, they get the care that is not needed by them. Other times, they don’t get the care that they really need!

Members also get affected! Good communication with the members is critical if they look to have a good experience with the member. Not so long ago, according to an AMA survey, nearly 70% of the physicians reported waiting for several days for prior authorization while 10% said that they had to wait for a week!

Insurance companies need pre certification for outpatient/inpatient hospital services, clinical procedures, medications and others. They are not going to pay for the service or the drug until the physician submits elaborate documentation describing the medical necessity for the service and the drug choice. In addition, prior authorization policies are different for every other insurance company.

To prevent rejections, there are a number of steps that a physician can take

Familiar with prior auth guidelines of payers: The surgeons have to be aware of the pre auth guidelines and the coverage and provide a specific diagnosis code in the reports. The codes tell the insurance why the service has to be performed and support the medical necessity.

Steps against denials: Providers need relevant information about medical procedures they perform routinely, enter into the contracting process with information. They must have the evidence for proving the medical necessity of the particular procedure as well as have the reliable sources on the coverage for a certain diagnosis.

Recommended treatment guidelines: Before a high-cost procedure for the patient, physicians should be making sure they follow the recommended guidelines for the treatments.

 A key study couple of years ago illustrated the challenges with prior authorization and medical necessity related to rejections being responsible for more than 11 % of all the denied claims. It usually occurs due to failure of securing an authorization in advance.

Sunknowledge Services Inc has the perfect answer to all your prior authorization challenges. We define your revenue by working as an extension of your operational arm. Our team will be providing you all the assistance and has the competence across all practice management/ billing systems. We are a one-stop destination for all prior authorization pains. Leverage the Sunknowledge opportunity and transform your cash flow!