The process of obtaining prior authorization is challenging for some ASC administrators also tasked with other financial duties.
Here's how three ASC leaders are managing prior authorization:
Note: Responses were lightly edited for style.
Girard Bullaro, administrator at Wellness ASC (McKinney, Texas): As a new ASC and struggling with razor-thin margins, we decided to hire a separate preauthorization specialist. Before this, we had four cases that fell through the gaps. These were spine cases, and we did surgeries thinking they were authorized but actually were not. Our staff at this time did not have the skill level to handle this complex procedure, and we lost revenue.
Since we hired an additional person to handle this task, we have had 100 percent compliance. With adding additional specialists and growing our volumes for 2021, we're looking at doubling our case volume. Margins are always going to be tight, and it's worth the extra cost of an additional person. It more than pays for itself.
Brock Kreienbrink, administrator at Outpatient Surgery Center of Central Florida (Wildwood): Prior authorization management is critical to the success of any ASC. Poorly managed authorizations can have a devastating impact on the finances of ASCs. To know the extent to how it can affect the finances at an ASC, administrators will need to know their patient populations in their market.
At our center we have a heavy Medicare market (close to 70 percent market share); however, there is a huge push for managed care, causing our market share of Medicare to shrink over the next five years. When a procedure is performed without the correct authorization, the ASC not only takes a loss on the revenue, medical supplies and labor — it decreases or eliminates profit margins on other procedures. The impact can be far-reaching, depending on the procedure mix, which makes it extremely hard to place a number on it.
Raghu Reddy, administrator at SurgCenter of Western Maryland (Cumberland): The prior authorization is a critical step, as the payers will deny the payment if proper authorization is not obtained. Based on our payer mix, we have to authorize 45 percent of our cases at our multispecialty center. We pay close attention to the prior authorization process, and the impact on our revenue is minimal.
We would notify the physician and the patient if the authorization were delayed or denied.