Referrals and Prior Authorization Process

Our experienced team verifies the patient’s plan type such as HMO, PPO or POS and determines if a prior authorization is required or not. If an authorization is not required, we will notify the clinic/provider’s office immediately so they can schedule the procedure.

• If we come across any new patient, we will verify whether the patient has referral from his/her primary care physician (PCP) and update the referral details in the patient account. If the new patient does not have a referral, we will notify the same to the doctor’s office or the clinic so that they can follow-up with the patient to get the referral.
• We will also inform the doctor’s office or client with the list of patients who has direct Medicare as they do not need any prior authorizations.
• If authorization is required for the procedure, visit or other treatments, our team will initiate prior authorization requests and obtain approval for the treatment and update the details in respective patient accounts in EHR and Practice Management System. If there is any delay in receiving the approval, we will follow-up with the insurance companies on the physician’s behalf until the approval for the submitted authorization is received. We provide our clients with complete coverage of the prior authorization requests with a 98+% accuracy and 99.5% adherence to turnaround time. We also work with Primary Care Physicians (PCPs) to refer the patients to the respective participating (in-network) specialists for a specific medical service based on patient’s medical conditions and the care the patient(s) need.
• We also collect supporting data from the PCP and/or patient such as prior treatments, related imaging or tests, and the urgency of the referral while submitting the referral requests to the specialists and to the insurance companies.

We periodically review open referrals and track down what happened, calling the specialist if needed. This step also involves confirming that the referring clinician acknowledges the specialist’s recommendations and that the patient attended the specialist appointment.

• We will communicate with referring physicians if the specialist does not see the patient for any reason. We will follow-up with the specialty practice to notify referring physicians of no shows, cancellations, or if the specialist referred the patient to another specialist who could more appropriately answer the clinical question.
• We help reduce this burden by making it easy for referring physicians to leverage their rendering providers’ prior authorization solution to obtain approvals during the referral process and in closing the referral loop.
• We also work on submitting prior authorization requests for all Outpatient hospital-based procedures referred by our specialists.
• We also work with the physicians mostly refer the patients to themselves in cases where the patient needs continuing care.