Prior Authorization

Why it's a margin item, not an errand

Home Care 101 names weak prior authorization on Medicare Advantage plans among the financial leaks that decide whether an agency's episodes are profitable — right alongside poor intake qualification, incorrect OASIS scoring, missed comorbidity capture, delayed physician signatures, billing lag, high LUPA rates and denials.

The mechanism is blunt: poor submission means delayed care and delayed cash. Care that waits on an authorization isn't delivered, and revenue that waits on an authorization isn't collected. Both show up in Days Sales Outstanding, and one of them shows up in outcomes.

Most agencies do not fail clinically. They fail operationally. Home Care 101 — Paradygm Health Group

Medicare Advantage changed the job

Traditional Medicare and Medicare Advantage do not behave alike, which is why intake's job includes identifying payer type and determining the prior-auth requirement before anything else happens. MA plans bring their own submission rules, their own timelines, and their own clawbacks — Medicare Advantage clawbacks sit in the same compliance environment as ADRs, UPIC audits, TPE reviews and medical review denials.

An authorization obtained late is a delay. An authorization obtained wrongly is exposure.

What we staff

• The submission itself — the documentation the plan actually asks for, assembled before it goes out rather than after a denial comes back.
• The chase — the follow-up work that determines whether the approval lands this week or next month.
• The handoff — requirement identified at intake, authorization secured, documentation started. One chain, not three inboxes.

You hire the person doing it as a dedicated remote employee at a flat monthly rate. They work your systems and your payer portals; they're ours to recruit, train, supervise and replace.

It isn't only a home-health problem

On the provider side of the business, insurance verification and pre-authorization run under the same principle — approval secured before services are rendered — as part of our MSO wrap-around. In an advanced wound care program, pre-treatment eligibility verification is a named best practice for staying compliant, because LCD compliance is mandatory for Medicare reimbursement and the product goes on the patient before the payer's opinion arrives.

The metrics it moves

Denial rates, Days Sales Outstanding, episode profitability, audit exposure. Faster, cleaner authorization is one of the small percentage improvements that compounds into meaningful annual margin.