Obtain and maintain longer, better authorizations

longer stays for clients with pre-authorizationsAddiction and substance use treatment facilities are facing tougher scrutiny from private insurance companies. As millions of Americans have received access to addiction treatment through the Affordable Care Act and the Parity Act, costs to insurers have soared. They, in turn, attempt to rein in costs in any way they can. Obstruction, denials and delays in payments result.

In this kind of environment, the focus for substance abuse facilities must be to work more effectively with the private insurers to obtain speedy and accurate VOBs (verification of benefits) and URs (utilization reviews). Providing financial clearance before a client walks in the door is essential to the financial health of the facility.

Similarly, maintaining authorization once a client is in a facility is crucial to successful treatment and business outcomes. This includes length of stay AND level of care. Extending authorization for a client without stepping them down to a lower level of care should be the goal.

Get more effective pre-authorizations

While essential, verification of benefits is not sufficient for an addiction treatment center to begin treating a client. After a facility’s intake team determine a preliminary level of care based on clinical information provided by the client, that treatment must be pre-authorized by the insurance company.

Pre-authorizing a client is a combination of science and art to ensure high quality initial authorizations. Obviously the bar for intensive outpatient (IOP) treatment is lower than partial hospitalization programs (PHP). If your pre-auth isn’t thorough and sensitive to that specific insurer’s requirements, obtaining that higher level of authorization is next to impossible.

Obtaining high quality pre-authorizations comes down to one main issue: the expertise of the utilization review coordinator. The higher their advanced degree, the longer they’ve been in this field, and the more experience they have with billing for addiction treatment, means the higher the quality of their initial authorization. They should be able to get PHP more easily with longer average stays.

Extend authorizations at the highest level of care

As with pre-authorization, concurrent reviews come down to the quality of the utilization review coordinator. In the PHP versus IOP example, an experienced and talented UR coordinator should be able to keep your client at the higher level of care for longer. They do that through a combination of skill and expertise (as mentioned above), but also through access to excellent clinical notes.

If clinical notes in the electronic medical records (EMR) are missing, improperly coded, or difficult to read, concurrent reviews will suffer. Without excellent documentation, even the most gifted utilization review professional will have one hand tied behind their back.

Get control of your billing and collections

Inspira prides itself on our pre-authorizations. Our utilization review team has more degrees and more experience than our competitors. Our UR department is lead by a PhD and every member of the team has many years of experience in behavioral health.

The quality of our initial authorizations is also higher than our competitors. We obtain more PHP vs IOP for our customers than their previous billing companies. We also get more authorized days and our concurrent authorizations extend stays beyond our competitors.

Contact Inspira to find out more about how we can improve your VOB and UR process or to provide training for your staff and clinicians.