February 2024

How to Establish Medical Necessity Through a Medical Record Review

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Establishing medical necessity is an important aspect of healthcare, especially when it comes to insurance reimbursement. Medical necessity refers to the requirement that healthcare services provided to a patient are appropriate and necessary to diagnose or treat a medical condition. One way to establish medical necessity is through a medical record review. A medical record …

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Top 10 Issues With Provider Credentialing

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Provider credentialing is a crucial process in healthcare that ensures the qualifications and professional background of healthcare practitioners. Despite its importance, provider credentialing can be a complex and time-consuming process. Here are the top 10 issues with provider credentialing: Overall, addressing these issues requires careful planning, adequate resources, and a commitment to ongoing quality improvement …

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What is The Difference Between a Pre-Authorization and a Post-Authorization

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A pre-authorization, also known as prior authorization, precertification, or prior approval, is used by insurance carriers to determine if the services being requested by your office are medically necessary for patients. Typically, a prior authorization request is sent before a service or procedure is provided to ensure proper payment when submitting a claim.  However, submitting …

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What is a Prior Authorization and Why is it Important

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What is precertification, prior authorization, or pre-approval? Today, many procedures and diagnostic tests, regardless of provider specialty, require prior authorization, but what exactly is it, and why do you need it? A prior authorization request provides information to the insurance carrier, who then will provide written confirmation that the procedure or diagnostic test can be …

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Verifying Medical Insurance Eligibility for Your Patients

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There are two steps to medical eligibility verification: patient eligibility verification and provider plan participation. Both verifications are necessary to ensure proper claim processing and reimbursement. The process of determining patient insurance eligibility includes verifying the patient’s insurance coverage, all covered benefits, deductible, co-insurance, and co-payment requirements. This step confirms not only what the carrier will …

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