New at prior authorizations

  1. I just accepted a position and have been exposed to prior authorizations. I knew about them but never had to do them. Anyone have information that might help me? I was given 4 to do and I felt like the deer caught in headlights. Since there are so many different insurance companies and forms, I feel overwhelmed.

    I have heard the common complaint that prior authorizations are time-consuming and a waste of money. Does it have to be done by an RN? Would it be more economical to have someone specifically trained in doing these? Any other RN's responsible for these?

    It's probably such a simple thing to do which makes it more confusing to me!
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  3. by   GAPLNC
    RN's are generally used for acquiring PA's because they require the submission of clinical information that must be extracted from the patient's record. Many PA's can be obtained on the insurance companies website or they have a form that is fax'd back with the information that they are requesting. Just contact the particular insurance company and find out what they want and if it can be done online. When you have to do it over the phone it is more time consuming but when done online it is generally faster.
  4. by   webbiedebbie
    Thanks for responding so quickly! I understand your reasoning for using RN's.
  5. by   codrn
    I have been working at an office for the past three months. I was hired to run clinic 3 days/week and "get authorizations" the other two. I don't mind this arrangement at all, however, a major part of this job (that was not disclosed to me during the interviews) is to create a patient's cost analysis based on their benefits. In other words, I figure out the allowable charges and calculate the patient's balance according to the coverage (80%/20%, etc). It is expected of me to present this bill essentially, to patients during their pre-operative appointment.

    Are there other clinic nurses out there doing this?

    Is this a typical part of a RN's job that obtains prior authorizations?

    It feels very awkward to me and a far stretch from what I thought I was getting myself into. However, I have never worked in a clinic before and it is hard for me to know for sure what is the norm.

  6. by   JMWilson08
    PA's are annoying when the pt has uncooperative insurance companies! I work in allergy and you wouldn't believe the hoops ppl have to jump through to get an antihistamine!
  7. by   xoemmylouox
    I am an LPN and my job involves PA's. I have been doing this for a few years now. They are time consuming and frustrating. I could be doing so much more if it wasn't for these ridiculous insurance companies. I have to say the most important thing to do is DOCUMENT DOCUMENT DOCUMENT. This includes names of reps you talk to, the phone numbers you called, etc. Good luck!
  8. by   codrn
    You will get the hang of it...once you figure out the same questions that ask over and over again. Just take a few minutes and review the patient's diagnostic findings, symptoms, series of treatments prior to making your phone call. It's time consuming but your speed will improve with each phone call. I often tell them I am fairly new at this and they may need to guide me a bit, some might think that is risky but it has worked for me.

    If anyone has any comments on RN's developing a patient's surgical pre-payment amount, I would love feedback. Do your billing personnel usually develop this? Thanks
  9. by   JMWilson08
    If anyone has any comments on RN's developing a patient's surgical pre-payment amount, I would love feedback. Do your billing personnel usually develop this? Thanks[/quote]

    At my job they have surgical MA's who do all the scheduling (I work at an ENT/Allergy practice). What specialty do you work in?