Eligibility, Prior Authorization, and Medical Necessity

Lynn M. Anderanin

Lynn M. Anderanin

Lynn Anderanin, CPC, CPPM, CPMA, CPC-I, COSC, has over 35 years’ experience in all areas of the physician practice, specializing in Orthopedics. Lynn is currently a Workshop and Audio Presenter. She is a former member of the American Academy of Professional Coders (AAPC) National Advisory Board, as well as several other boards for the...
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60 Mins
Lynn M. Anderanin

Importance of Eligibility, Prior-Authorization, and Medical Necessity to avoid Claim Denials

Insurance companies are making it harder every day to give patients care without meeting their requirements for procedures with eligibility, prior-authorization, and medical necessity. A patient’s insurance coverage must be current, and then the policies of the insurance company have to be followed in order to receive payment. Not authorizing services or procedures that the insurance companies require will result in a denial that cannot be billed to the patient. Even when prior-authorization is obtained, if you haven’t met the medical necessity guidelines, the claim is not guaranteed payment. In addition to these complexities, medical offices are expecting to keep up with the different changes for each of the insurance carriers they are contracted with, which can happen almost daily. The insurance companies publish changes, but many changes are quietly implemented and the only way offices become aware is when they receive a denial.

Join this information-packed webinar, where expert speaker Lynn M. Anderanin not only talk about organizing eligibility and prior-authorization in a medical office, but will also look in-depth at the problems that can occur and steps to take to feel confirmation that you have met the insurance company requirements for eligibility, prior-authorization, and medical necessity. This will ensure that your claims will be paid according to the insurance company guidelines that you followed.

Webinar Agenda

  • Using the various methods available to verify eligibility.
  • Determine if a service or procedure requires prior-authorization
  • Adjusting prior-authorization if new procedures or services are performed
  • Understand how to use insurance company policies to meet medical necessity
  • Submit clean claims with all of the necessary information

Webinar Highlights

  • “On the fly” eligibility
  • Clearinghouse and other programs for eligibility
  • Completing prior-authorization forms
  • What to do when prior-authorization is denied
  • Retro-authorization and the problems it creates
  • ICD-10-CM diagnoses coding for medical necessity
  • Documentation requirements for appeals

Who Should Attend

  • Coders 
  • Billers 
  • Collectors 
  • Manager 
  • Supervisor
  • Authorization Specialist
  • Surgery Schedulers 
  • Receptionists
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