If I could improve one health insurance policy tomorrow, it would be the accountability surrounding prior authorizations and coverage determinations. One of the things that has always stood out to me is the disclaimer that is given whenever you call a health plan. You’re told that the information you’re receiving is not a guarantee of payment and may not be the most current information available. Then, even after a prior authorization has been approved, you’re told the same thing—that an authorization is not a guarantee of payment. As someone who works in revenue cycle, I understand why those disclaimers exist. Eligibility can change. Benefits can terminate. Claims can deny because of coding errors or because services were performed outside of what was authorized. Those situations make sense. Where I believe we need change is when the health plan has already completed its own clinical review and approved a service—especially through the appeal process. I once worked with a patient who needed a medication that did not initially meet the plan’s medical policy based on her diagnosis. However, she had multiple co-occurring autoimmune conditions and was being treated not only by our physician but also by the Mayo Clinic. We submitted an appeal with additional clinical documentation demonstrating why this medication was medically necessary despite not fitting the standard guideline. After reviewing the case, the health plan approved the medication as an exception. That should have been the end of the story. Instead, when the claim was submitted, it denied because the diagnosis itself wasn’t covered. To me, that’s where accountability breaks down. The health plan had already reviewed the clinical evidence, considered the exception, and made the decision to approve the treatment. If the plan determined that this patient qualified for an exception, the claim should not later deny for the very reason that had already been reviewed and overturned. In our case, the organization ultimately wrote the balance off. Personally, I would have continued fighting because I believe the approval supported payment. Unfortunately, not every business office has the time, resources, or understanding of the front-end revenue cycle to continue appealing after a claim denies. Too often those claims become write-offs, provider losses, or unnecessary patient frustration.

What area of healthcare insurance do you currently work in, and what is one challenge you encounter regularly in your role?

@Jessica Gentry Neurology is quite interesting. We have neurology at my current practice. They joined us at the beginning of this year. One of our physicians is a neurology and ophthalmologist. He is one of those rare providers who do both in our area. Well, he is the only one that practices both in our region. I didn’t even know it was a thing before meeting them.

For me, the biggest positive impact came from improving our workflow. When I first joined my team as an Insurance Verification Representative, I quickly realized we weren’t really operating with a defined workflow. We were constantly reacting to whatever was in front of us, which meant there wasn’t much accountability and we were always working from a backlog. Before I ever became a Lead, I changed the way I approached my own work. Every morning I focused on what came in that day, and every afternoon I worked through the older cases. That simple shift allowed me to stay current while steadily reducing the backlog. Over time, other team members adopted the same approach, and eventually we eliminated the backlog altogether. Once I became a Lead, I had the opportunity to build a more intentional workflow. We documented our processes, created checkpoints for accountability, and developed a system that helped team members know where they stood and helped leadership identify when someone needed support. As I transitioned into supervising the department, we continued refining that workflow—not just for our own team, but for the departments we partner with, our providers, and ultimately our patients. Every adjustment was made with one goal in mind: reducing delays and creating a more efficient experience for everyone involved. Looking back, the workflow itself wasn’t the biggest improvement. It was creating a process that gave people clarity, accountability, and the ability to continuously improve instead of simply surviving the day. The goal wasn’t just to eliminate the backlog. It was to build a workflow that allowed us to stop living in maintenance mode and start working proactively. Dinah 💕

You’re also welcome to share the area you work in (payer, provider, pharmacy, advocacy, etc.) and what types of coverage issues you encounter most often. What is one coverage or access challenge you are seeing more frequently in your work right now?

I wanted to take a moment to share the area I work in. I currently work within a health system, supervising an amazing team that manages insurance verification, pre-certification, and scheduling for our radiology department. I also continue to assist with prior authorizations and coverage issues across other service lines as needed. One access challenge we’re seeing more frequently is patients not being properly registered with third-party administrators. When the payer’s system and the administrator’s system don’t align, it creates significant delays in verifying coverage and obtaining authorizations. It can be incredibly time-consuming for both healthcare teams and patients, often requiring multiple calls and additional follow-up just to get the systems synchronized before care can move forward. It really highlights how disconnected systems can become a barrier to timely patient care. I’d be interested to hear if others are seeing similar issues with third-party administrators or other payer system mismatches. Dinah💕

@Jessica Gentry Hello and welcome, Jessica! Congratulations on pursuing your bachelor’s degree in Healthcare Administration. Healthcare is one of the most rewarding fields you can choose because of the opportunity to make a real difference in people’s lives. Whether you find yourself on the provider side, the insurance side, or somewhere in between, you’ll have countless opportunities to learn, grow, and serve others. Buckle up—you’ve chosen the ride of a lifetime! Wishing you all the best on your journey.