Eligibility, Prior Authorization, and Medical Necessity

September 09, 2021
60 Mins
Lynn M. Anderanin
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In an effort to manage healthcare costs insurance companies have several programs that need to be addressed to ensure a claim will be paid, but with still no guarantee. Many services require authorization to be obtained before  services and procedures are performed.  Insurance companies are constantly changing their prior-authorization requirements. It is also common that employers will change insurance plans to save money on monthly premiums. This webinar will walk through how offices can obtain eligibility before the patients are seen to confirm that the insurance information that is available is accurate and the patient is covered for services to be rendered. Then when the patient is seen, any services or procedures that are ordered may need to be prior authorized for that reimbursement will be received. The final piece is that the medical necessity requirements for the procedure or service is being met according to insurance company policies and guidelines.  Attendees will benefit from this webinar in that we will discuss all of these aspects of a medical claim that may have to occur before the insurance company even processes it and will reduce the number of claims an office can receive because these steps were not taken. This session will address the differences between eligibility, prior-authorization, and medical necessity and give attendees the steps needed to help ensure that claims will be submitted to the correct insurance company with the requirements of the insurance company met based on guidelines and policies set by the insurance company.

Webinar Objectives

When a patient presents an insurance card proving medical coverage this is not guarantee that all services and procedures will be reimbursed by the insurance company. It is up to the office to confirm eligibility for the date services are rendered, obtain prior authorization for those services and procedures the insurance company requires to be pre-authorized, and to have knowledge of the specific insurance company’s policies on medical necessity for the services and procedures performed. Knowing and understanding each of these elements will allow a more successful and timely turnaround for claims reimbursement.

Webinar Agenda
  • Methods of obtaining patient eligibility
  • Information received from eligibility
  • Medicare options to patients
  • When Prior Authorization is necessary
  • Tricks to receiving authorization for coding options
  • Major insurance carrier information for eligibility and prior authorization
  • How to determine medical necessity
  • Interpreting insurance carrier policies
  • Managing claims denials
  • Writing effective appeals
Who Should Attend
  • Consultants
  • Auditors
  • Compliance Officer
  • Physician
  • PA
  • Nurse
  • Biller
  • Coder
  • Collector
  • Claims Representative
  • Claims Adjuster
  • Claims Processor
  • Manager
  • Supervisor
  • Administrator
  • Medical Assistants
  • Office Staff
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 AAPC. She is also the founder of her Local Chapter of the AAPC.
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