Improving Infusion Center Profitability with a Robust Prior Authorization and Advocacy Process

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By Monique Lappas

The ultimate goal of most providers is to provide exceptional patient care; however, making a profit and having a consistent revenue cycle is necessary to achieve that goal.

For those providers that offer infusion services, you will find that focusing on two key areas will have a significant impact on both your profit and revenue cycle stability.

  1. Insurance Verification Process and Prior Authorizations
  2. Patient Financial Advocacy

The Insurance Process

Many infusion centers struggle to be profitable due to their lack of resources for what most would imagine to be a simple step verifying and qualifying patient insurance. As practice managers know, 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? This occurs when the intake department contacts the insurance carrier (which can be time-consuming) either over the phone, through an EMR system – if offered, or through another platform like Availity.

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?

Step 3: Prior-Authorization (PA):

Once you have determined that the patient’s insurance plan requires prior authorization, which is often 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. 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 the extensive undertaking that many prior authorizations require.

Services like those offered by Q Consulting Support Services (QCSS) exist to help practices maintain a stable and strong revenue cycle by working with the provider, the billing team, the patient and insurance companies to guarantee a seamless verification and prior authorization outcome. These types of outsourced providers have dedicated teams of prior authorization specialists, who understand what the insurance company needs, where hurdles might exist and ways to overcome them. 

Reducing Bad Debt through Patient Financial Advocacy

Once the prior authorization of a patient is received, the financial advocacy team should take over by identifying patients that are under-insured or have high out-of-pocket costs. These experts look for solutions to help patients alleviate the financial burden of their infusion costs. Importantly, it also ensures that the provider receives payment for services delivered. 

When patients are unable to afford the out of pocket costs that they have accumulated because of their treatment, providers face a tough decision:

  1. Send the patient a constant stream of letters and notices informing them of their outstanding balance due.
  2. Write off the payment as bad debt and carry it on their balance sheet with the expectation that payment is unlikely.

Patients are often unaware of the extent of their out-of-pocket expense before their treatment and in many cases, even if they are aware, are unable to afford them. 

Improving Cash Flow Management

Most providers will bill insurance on a regular basis to ensure ample cash flow and will proactively send out a series of notices to patients to settle outstanding accounts. In these notices, the patient is instructed to submit payment within a given timeframe. If payment is not received, the provider will send the patient to collections (likely lowering patient satisfaction scores). 

Using a billing and collection process as the only means to collect monies owed is inefficient and usually unsuccessful. 

There is a Better Way

There are many ways to avoid the ‘bad debt’ cycle that your practice might find itself in, particularly when helping patients cover their infusion and in-office drug costs. By taking advantage of many of the manufacturers, foundation, and non-profit support programs, it is likely that your patients will be able to find the help they need to cover their out-of-pocket costs.

Monique Lappas, founder and CEO of Q Consulting Services, provides consulting and support services that saves hospitals and healthcare providers time, money and lives. She has worked with over 400 hospitals, across the United States and Canada, with clients ranging from critical-access hospitals to the country’s largest healthcare systems.

Monique has had to tap into much of her knowledge base, both in healthcare, finance and business management, to make the business a success. Her background in healthcare has spanned over 20 years. It began as a Quantitative Analyst for an investment bank in Sydney, then as an analyst covering the Emerging Markets at Wellington Management in Boston, MA and continued through to Wasatch Advisors in Salt Lake City, UT. In these roles, she analyzed healthcare service providers, pharmaceutical companies and hospitals from an investment perspective. She also spent time working within the investment banking healthcare team at Goldman Sachs and within the M&A division of a large Australian industrial company.

Monique hails from Sydney, Australia. She holds a B.Comm from Bond University (Australia), an MBA from the Tuck School of Business at Dartmouth and has also earned the Chartered Financial Analyst (CFA) designation.

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