Summary
In this episode, Sean and Terry Fletcher discuss the complexities of prior authorization in healthcare, emphasizing its critical role in the reimbursement process. They explore the misconceptions surrounding prior authorization, the disconnect between healthcare providers and payers, and the challenges posed by Medicare Advantage plans. The conversation highlights the importance of compliance, medical necessity, and the legal aspects of prior authorization, providing insights for healthcare professionals navigating this intricate system.
Takeaways
<ul>
 <li>Prior authorization is essential but does not guarantee payment.</li>
 <li>There is significant misinformation about prior authorization processes.</li>
 <li>The volume of prior authorization requests has been increasing annually.</li>
 <li>Medicare Advantage plans often complicate the reimbursement process.</li>
 <li>Providers must understand their insurance coverage limitations.</li>
 <li>Patients often believe all services requested by doctors are covered.</li>
 <li>Compliance in prior authorization is crucial for healthcare organizations.</li>
 <li>Medical necessity must be documented alongside prior authorization requests.</li>
 <li>The process for obtaining prior authorization can vary significantly by payer.</li>
 <li>Healthcare providers need to be proactive in managing prior authorizations.</li>
</ul>

Summary In this episode, Sean and Terry Fletcher discuss the complexities of prior authorization in healthcare, emphasizing its critical role in the reimbursement process. They explore the misconceptions surrounding prior authorization, the disconnect between healthcare providers and payers, and the challenges posed by Medicare Advantage plans. The conversation highlights the importance of compliance, medical necessity, and the legal aspects of prior authorization, providing insights for healthcare professionals navigating this intricate system. Takeaways Prior authorization is essential but does not guarantee payment. There is significant misinformation about prior authorization processes. The volume of prior authorization requests has been increasing annually. Medicare Advantage plans often complicate the reimbursement process. Providers must understand their insurance coverage limitations. Patients often believe all services requested by doctors are covered. Compliance in prior authorization is crucial for healthcare organizations. Medical necessity must be documented alongside prior authorization requests. The process for obtaining prior authorization can vary significantly by payer. Healthcare providers need to be proactive in managing prior authorizations.

Season 8 - Episode - 2 - #TerryTuesday

Sean is the host of “The Compliance Guy” a live production dedicated to the intersection of regulatory compliance and the business of medicine. The show provides timely, accurate, and easy to digest information to healthcare professionals.
The show features interviews of industry leaders, government officials, and others helping to shape the healthcare landscape.
Sean M. Weiss (AKA – The Compliance Guy) has been an industry respected name for more than 25-years. A physician and health system advocate, Sean engages with clients to ensure a “level-playing-field” and due process when allegations and/or accusations of impropriety are leveled by a payor or government investigation agency.


When Sean is not engaging in administrative, civil and criminal matters on behalf of more than 30 nationally recognized law firms and clients, he is serving as a third-party compliance officer for a dozen organization across the country ranging in size and specialty to ensure a “Culture of Compliance”!


Sean is a proud member in good-standing with the National Society of Certified Healthcare Business Consultants (NSCHBC), American Health Lawyers Association (AHLA), National Alliance of Medical Auditing Specialists (NAMAS), and the American Academy of Professional Coders (AAPC). Sean holds (CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC, CMC, CMIS, CMOM) national certifications from the Health Care Compliance Association, The National Alliance of Medical Auditing Specialists, The American Academy of Professional Coders and Practice Management Institute.

Business

Sean is the host of “The Compliance Guy” a live production dedicated to the intersection of regulatory compliance and the business of medicine. The show provides timely, accurate, and easy to digest information to healthcare professionals. The show features interviews of industry leaders, government officials, and others helping to shape the healthcare landscape. Sean M. Weiss (AKA – The Compliance Guy) has been an industry respected name for more than 25-years. A physician and health system advocate, Sean engages with clients to ensure a “level-playing-field” and due process when allegations and/or accusations of impropriety are leveled by a payor or government investigation agency. When Sean is not engaging in administrative, civil and criminal matters on behalf of more than 30 nationally recognized law firms and clients, he is serving as a third-party compliance officer for a dozen organization across the country ranging in size and specialty to ensure a “Culture of Compliance”! Sean is a proud member in good-standing with the National Society of Certified Healthcare Business Consultants (NSCHBC), American Health Lawyers Association (AHLA), National Alliance of Medical Auditing Specialists (NAMAS), and the American Academy of Professional Coders (AAPC). Sean holds (CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC, CMC, CMIS, CMOM) national certifications from the Health Care Compliance Association, The National Alliance of Medical Auditing Specialists, The American Academy of Professional Coders and Practice Management Institute.

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Season 8 - Episode - 2 - #TerryTuesday

Season 8 - Episode - 2 - #TerryTuesday

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