Our Payer Requirement Framework Building Blocks

Payer Requirement Framework 

Using our data-driven methods, we develop a comprehensive framework for your organization that addresses your payer requirements. This framework ensures that all procedures and services are approved before they are performed. Based on scheduled services or orders placed, we identify scenarios that require approval. Our continuous improvement model continually analyzes and identifies other unknown scenarios that require authorization and updates your framework accordingly.

Authorization Required Automation

We provide an automated process for evaluating scheduled services against your custom framework to identify authorization requirements. This automation will also update the required authourization fields accordingly.

Missing Authorization Post-Service

We’ve noticed clients obtaining authorizations but not assigning those authorizations to the correct visits before billing, resulting in denial. We implement actions to prevent this and avoid those unnecessary denials. We don’t just fix authorizations in the queue; we also fix historical denials. We’ve created an additional action that automates past denial appeals by attaching the authorization and queuing up for appeal to the payer.

Authorized vs. Performed Services Discrepancy 

At times, a specific procedure or service is authorized, but the services performed may differ from the initially ordered ones for various reasons. SparkChange has created an automated process to detect discrepancies and initiate retro-authorization before billing.

Custom Edits

As a failsafe measure, we’ve created custom edits that are built in to ensure that any claim missing a required authorization is stopped before generating to prevent unnecessary denials.

Authorization Denial Automation Monitoring  

Review CARC denials to see if authorization was required and obtained. We will trigger a work item to request an appeal if we determine it was obtained. If the denial did not require or have an authorization present, we will use these to build on the matrix for future authorizations required and can trigger a separate work item to have a user review.