Prior-Authorization and Medical Necessity

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Course Description

This webinar will discuss the basics of insurance coverage, eligibility, and prior authorization to assist providers in obtaining this information from insurance companies to help patients understand what their insurance will pay, and what may be their responsibility. Attendees will learn the differences between a patient’s insurance coverage, eligibility, and prior authorization and then be able to apply their knowledge in their office. Most insurance companies offer different plans that cover different services and procedures. Once an office has verified that a patient is eligible for benefits on a particular day, the coverage will determine what the insurance company will pay, and what may be the responsibility of the patient. We will also look at the ins and outs of contacting the insurance company of prior authorization and what to do in the circumstances when the procedures performed change during the surgery.

Learning Objectives

• Understand the difference between insurance coverage and prior authorization
• Realize the role medical necessity plays in the authorization and reimbursement process
• Learn the importance of eligibility processes before the patient is seen
• Implement an eligibility plan in their office
• Reduce the number of retro-authorizations
• Apply insurance carrier guidelines to be able to meet medical necessities
• Obtain the most accurate prior authorizations for maximum reimbursement
• Understanding the intricacies of Prior Authorization
• Deciphering the workflow of the Prior Authorization process
• What are the implications of Prior Authorization delay
• Trends in the healthcare system
• How to better navigate prior authorization requests

Areas Covered in the Session

• Insurance Companies websites for prior authorization
• Medicare procedures that require an authorization
• Medical necessity and where can the information be found
• Working with scenarios when what was authorized is not what was done
• Medicare NCD and LCD
• Other ways to find out information about prior authorization
• Eligibility vs. prior authorization
• The use of technology for authorization
• Medicare information related to medical necessity and how different it can be from one geographical location to another
• Denials caused by prior authorization troubles and how to appeal them
• Live Q&A session

Suggested Attendees

• Billers
• Coders
• Administrators
• Managers
• Supervisors
• Physician
• Non-Physician providers
• Qualified Healthcare Professionals
• Surgery Schedulers
• Claims adjusters
• Case Managers
• Physician Assistants
• Revenue Cycle Staff 
• Caseworkers
• Nurses
• Reimbursement Staff
• Practice Manager
• Insurance Claim Processors
• Reimbursement Specialist and Staff 
• Non-Physician Practitioners 

About the Presenter

Lynn M. Anderanin, CPC, CPB, CPMA, CPC-I, CPPM, COSC is the Sr. Coding Educator for Healthcare Information Services, a revenue cycle management and consulting service in the Chicagoland area. Prior to relocating to Chicago, Lynn was the Billing Office Manager and surgical coder for Hand Surgery Associates, now Michigan Surgery Specialists in the Detroit Area. She has over 39 years of experience in all areas of the physician practice including Practice Administrator, Billing Manager, and Director of Operations. Her experience is primarily in the specialties of Orthopaedics, Rheumatology, and Hematology/ Oncology. She has been a speaker for many conferences, including the AAPC National Conferences and Workshops, Community Colleges, Audio Conferences, Certification classes, and Webinars. Lynn became a CPC in 1993, a Certified Instructor in 2002, a Certified Orthopedic Surgery Coder in 2009, an examination in which she participated in creating. She passed the Certified Practice Manager exam in 2015, the Certified Medical Auditor exam in 2016, and the Certified Professional Biller exam in 2021. Lynn is the founder of the first local chapter of the AAPC in Chicago, which is now 25 years old, and a former member of the AAPC National Advisory Board as well as several other committees for the AAPC.

Additional Information

After Registration: You will receive an email with login information and handouts (presentation slides) that you can print and share with all participants at your location.

System Requirement:

• Internet Speed: Preferably above 1 MBPS
• Headset: Any decent headset and microphone which can be used to talk and hear clearly

Can’t Listen Live? No problem. You can get access to an On-Demand webinar. Use it as a training tool at your convenience.

For more information, you can reach out to the below contact:

Toll-Free No: 1-302-444-0162

Email: care@skillacquire.com 

This is a Live Virtual session.

A new way of immersive learning that allows you to engage live with our instructor and peers providing you with the flexibility to juggle the new work-life balance.

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