Clinic-specific requirements are a must-have.
Beeline Data Stories
There’s a hidden tug-of-war between specialists and HMO plans.
Prior auth is often seen as a gate-keeping tool for plans to limit unnecessary costs, but specialists impose their own prior-auth requirements to help guarantee coverage of services. In fact, Beeline has found that 1 in 4 routine referrals are kicked back by specialists to modify the prior auth details.
Sometimes the change is benign, such as which provider is named on the approval. Another common pitfall is which CPT codes are required for cataract surgery: routine or complex. And sometimes the specialist is systematically up-coding prior auths to lock in more lucrative payments and triage more lucrative patients.
Whether these changes are warranted clinical escalations, clerical errors, or waste, patient care is delayed every time.
And delayed patients don’t just wait. They end up in urgent care or the ER for something that could, and should, have been handled in a specialist’s office. These experiences and costs are fully avoidable.
Beeline Health centralizes specialist-specific requirements so that correct, complete referrals are sent to the best possible specialist.
💛 About Beeline
Beeline helps every patient access the right specialist the first time. We provide the missing insights and decision support to ensure every patient’s access to the optimal specialist.
This post is part of an ongoing series of real Beeline data and referral stories, highlighting lessons learned and our impact on patient access.
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