Understanding Eligibility, Prior Authorization, and Medical Necessity

Healthcare providers often face challenges navigating the requirements set by insurance companies to ensure claims are processed and paid. Even with the proper steps taken, there is no guarantee of payment. Many services require prior authorization, which must be secured before performing certain procedures. Insurance companies frequently update their prior authorization rules, and changes in employer-provided insurance plans can complicate matters further.

This webinar will guide healthcare professionals through the process of verifying patient eligibility before services are rendered, ensuring that insurance details are accurate and up-to-date. We will also cover the necessary steps for obtaining prior authorization for specific services and procedures to facilitate reimbursement. Additionally, we’ll discuss the importance of meeting medical necessity criteria as defined by insurance companies, which is crucial for claim approval.

By attending this session, participants will learn to navigate the complexities of eligibility, prior authorization, and medical necessity, significantly reducing the risk of claim denials and improving the efficiency of the claims process. The webinar will provide actionable steps to ensure claims are submitted correctly and comply with insurance company guidelines and policies.

Webinar Objectives

Presenting an insurance card does not guarantee coverage for all services and procedures. Offices must verify patient eligibility for the date of service, secure prior authorization when required, and understand the insurer’s medical necessity criteria for the services performed. Mastering these components will enhance the success rate and speed of claim reimbursements.

Webinar Agenda

• Techniques for verifying patient eligibility
• Key information obtained through eligibility checks
• Medicare options available to patients
• When and why prior authorization is required
• Strategies for securing authorization, including coding tips
• Key policies of major insurance carriers on eligibility and authorization
• How to assess and confirm medical necessity
• Deciphering insurance carrier policies
• Approaches to managing claim denials
• Crafting effective appeal letters

Who Should Attend

• Healthcare Consultants
• Auditors
• Compliance Officers
• Physicians
• Physician Assistants (PAs)
• Nurses
• Medical Billers
• Coders
• Claims Collectors
• Claims Representatives
• Claims Adjusters
• Claims Processors
• Managers
• Supervisors
• Administrators
• Medical Assistants
• Office Staff

This webinar is designed for anyone involved in the medical billing and coding process, aiming to enhance their understanding of the complex insurance claim landscape.