2021 Annual Meeting Startup & Practice Management Access Pass-Congressional Updates That Will Affect You: Surprise Billing, Pre-Certification and E&M

Video Transcription

Video Summary

In this video, the speaker discusses the issue of prior authorization in healthcare. Prior authorization is a procedural check run by insurance companies before coverage is provided for services, but it can be seen as a way for providers to deny payment for medical services they want to perform. The speaker explains that there are two types of denials: prior authorization (prospective denial) and retrospective denial. The average in-network denial rate is 17%, but it varies by state and provider. Patients rarely appeal denials, and the appeals process is labor-intensive and costly for providers. Prior authorization has become more common, and it is estimated that 40 to 50 million people will require it in the near future. The practice was introduced by commercial payers, Medicaid, and Medicare Advantage. The concerns with prior authorization include interfering with patient autonomy, delaying care, and increasing administrative burden. However, there have been studies showing cost savings in certain areas, although delaying definitive care can lead to increased costs. Some proposed solutions include designating providers with high compliance as exempt from prior authorization, sunsetting frequently overturned appeals, and increasing automation and electronic processing. The speaker mentions a specific bill, HR 3173, Improving Seniors' Timely Access to Care Act, which aims to standardize pre-certification electronic processes for prior authorization and increase transparency and real-time decisions. The bill has bipartisan support, and action on it is expected in the second half of the year. Viewers are encouraged to stay updated on any changes and support the bill. No credits were mentioned in the transcript.

Asset Caption

Dr. Eric Stiefel

Keywords

prior authorization

healthcare

procedural check

denials

insurance companies