Prior Authorization (PA) and Utilization Management (UM) are processes used by healthcare providers and insurance companies to ensure that certain medical services, procedures, or medications are necessary and appropriate before they are approved for coverage.
Prior Authorization is a process where healthcare providers must obtain approval from the insurance company before performing certain procedures, prescribing specific medications, or ordering certain tests. This is done to ensure that the requested service is medically necessary and meets the insurance company’s criteria for coverage. The provider typically needs to submit relevant medical information and documentation to support the request.
Utilization Management, on the other hand, is a broader process that involves reviewing and managing the use of healthcare services to ensure they are appropriate, necessary, and cost-effective. It includes activities such as pre-authorization, concurrent review (reviewing ongoing treatments), and retrospective review (reviewing past treatments).
Both Prior Authorization & Utilization Management aim to control healthcare costs, prevent unnecessary or inappropriate services, and ensure that patients receive the most appropriate care. These processes can sometimes be time-consuming and require coordination between healthcare providers, insurance companies, and patients.
Prior Authorization & Utilization Management that Works for You
Insurers are increasingly contracting with third-party vendors of utilization management programs to administer the rehabilitation benefit. This can create both challenges and opportunities for behavioral health addiction treatment centers.
Before insurance companies will agree to pay for some medications, medical procedures, and medical equipment, they require advance notice. Utilization management programs are also an essential part of a provider organization’s revenue cycle, helping to prevent unnecessary costs and claim denials.
Expert Advocates, Effective Appeals
At Synergy Concepts, our utilization review specialists are passionate professionals with experience specific to the addiction treatment behavioral health field.
Our prior authorization and utilization review services are conducted by our team of qualified insurance management process experts to ensure your patients receive the best advocacy and treatment possible.
We work closely with our addiction treatment and behavioral health providers to make sure they understand the key elements of the authorization process, including but not limited to; superior clinical documentation, medical necessity guidelines for each insurance carrier, intricacies of the authorization, and utilization review processes.
Quality Services
Our team has developed a solid reputation as ethical and caring for you and your patients. We know what information is needed and work closely with clinical staff to monitor and review behavioral health services rendered and provide clinical data on diagnosis, diagnostic test results, symptoms, and conditions supporting the requested services to obtain the highest number of authorized days.
Our Behavioral Health Utilization Management Services Include:
- Pre-authorization of services
- Concurrent planning, discharge planning
- Medical record review to determine proper documentation supporting billed medical services
- Assist in educating clinical staff in medical record reviews and clinical case appeals. This shows proper documentation that supports the billed services
Valuable Services
Experienced the value of our tried and true utilization management approach. We have an effective appeal process with elevated overturns 44% of authorization denials. Let us help you control healthcare costs, increase revenue, and improve patient outcomes.
Contact Synergy Concepts
Contact us to find out how Synergy Concepts can help your facility. Send us an email using the form below with any questions you have about working with us. Let us do your Prior Authorization & Utilization Management for you.
How Can We Help?
Our expert team is ready to jump-start your growth.
See How We Can Boost Revenue & Drive Business Growth
Fill out the form, and someone from our team will reach out as soon as possible.