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Improving Infusion Center Profitability with a Robust Prior Authorization Process

Hospitals can improve infusion center profitability by focusing on one area - the Insurance Verification Process and Prior Authorizations.

Numerous factors have contributed to the shift of outpatient infusion services from the private practice setting to the hospital outpatient setting. As this trend continues, hospitals must focus on one area that can help guarantee the center's profitability: verifying patient insurance benefits.

Many outpatient hospital-based infusion centers struggle to be profitable due to a lack of resources required to verify patient insurance. The verification process consists of three components: Verification, Eligibility, and Prior-Authorization.

Let us break down each component:

Step 1: Insurance Verification:

Does the patient have insurance, and are the infusion services covered under their plan? The intake department completes the verification process upon admission by calling the insurance carrier (which can be time-consuming), through the EMR system – if offered, or through another platform like Availity.

Verification of benefits ensures the patient has coverage for the specified treatment plan and indicates if prior authorization is required.

Step 2: Eligibility

During the insurance verification process, you must also determine the plan's eligibility period. Is the patient eligible for services during the time that you will be performing the infusion? Completing this step before EACH infusion ensures there is no lapse in coverage or that the policy is still active and has not been terminated (which can happen for various reasons).

Step 3: Prior-Authorization (PA):

Once you have determined that the patient's insurance plan requires prior authorization, you must ensure the patient meets the plan requirements. This process generally requires sharing information from the patient's medical record. Providing the medical record will establish medical necessity and explain why the physician prescribed one drug over another more affordable option– possibly due to previous product failure or patient allergy. The health insurance company will review the physician's recommendation and either approve or deny the authorization request.

It is imperative to note that medical care will need to be approved by the insurance carrier before treatment is received. The medical claim will be denied without prior authorization.

The prior-authorization process can be burdensome. According to the American Medical Association (AMA), 9 in 10 physicians find that prior authorizations have a negative impact on patient outcomes and believe the burden associated with PAs has increased over the past five years.

Revenue Cycle Management (RCM) and Prior Authorizations

Prior authorizations are a pain point for providers yet are crucial to the revenue cycle and clinical care operations. The RCM process ensures that patients can access the necessary care and providers get paid for delivering services.

Patient Revenue is tracked and managed through the RCM process, starting at the initial encounter through to the final payment. The cycle encompasses all administrative and clinical functions contributing to capture, management, and collections from the patient and their insurance provider.

Revenue Cycle Management is critical to operating a thriving infusion center; It requires the strategic management of Insurance Verification, Eligibility, and Prior Authorization. With the rising cost of drugs, shrinking margins, and overall changes in the drug and healthcare industry, providers need to be sure they have a knowledgeable team who can sustain a healthy revenue cycle.

Everyone plays a vital role in ensuring correct reimbursement for these high-cost drugs – but most organizations or infusion centers do not have adequate staffing or additional resources for such an undertaking.

Financial Advocacy - Supporting a Healthy Revenue Cycle

Q Consulting Support Services (QCSS) provides a team of financial advocates that can help the infusion center maintain a revenue cycle that maximizes revenue collection while keeping the patient at the center of each transaction.

QCSS is a full-service insurance verification, prior authorization, financial counseling, financial advocacy, and specialty pharmacy management program.

Most importantly, we begin by verifying insurance benefits so both the provider and the patient know the out-of-pocket expenses related to the planned treatment. Once our financial advocacy team identifies patients that are under-insured or have high out-of-pocket costs, we determine which supplemental coverage sources are available to help manage their healthcare costs and ensure the provider receives payment for services delivered. We continue to oversee the entire reimbursement process, whether for a Manufacturer Copay Card, Foundation Assistance, or Free Drug through a Patient Assistance Program.

QCSS will also manage the Prior Authorization Process to guarantee that patients get access to the medications they need on time - alleviating the clinical team's administrative burden and allowing them to focus on patient care.

The revenue cycle in healthcare is complex, requiring continuous process improvements to keep pace with the ever-changing industry. QCSS would welcome the opportunity to partner with your infusion center to improve your revenue cycle and assist your staff and patients with all their financial assistance needs.