Prior authorization outsourcing: submissions and follow-up
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Give each request a recorded status, a next action and an owner. Keep clinical decisions with the practice.
Actigy BPO provides prior authorization outsourcing for practices, clinics and billing companies. Headquartered in Prague, Czech Republic, the nearshore business process outsourcing (BPO) company handles approved submissions, payer follow-up and status records. A queue-specific process audit defines the paid pilot. Providers retain clinical decisions; payers determine authorization and payment.
Share request volume, payer mix and required hours. Do not send patient records.
What the administrative service takes on
- Administrative intake, document collection, submissions, payer follow-up and status tracking within the written scope.
- Work in client-approved systems, with missing clinical evidence returned to the provider.
- A process audit and paid pilot before expanding the request queue.
- No clinical review, medical-necessity decision or guarantee of payer approval.
| Buyer | Practices, clinics and billing companies with recurring authorization administration |
|---|---|
| Delivery | Teams in Bulgaria, Romania, Poland and Ukraine; locations agreed before access |
| Coverage | Agreed working shifts and payer-call windows, not assumed full-US-day availability |
| Pricing | Usually per full-time equivalent (FTE) by role, quoted after the process audit |
| Start | A paid pilot after access, training, records and review owners are ready |
| Client retains | Clinical facts, medical necessity, care, approved submission rules and patient communication policy |
Keep eligibility, authorization and billing separate
Authorization administration can move separately from the rest of the revenue cycle. Eligibility and benefits verification checks the plan and reported coverage. An authorization request asks the payer for a determination about a proposed service. Neither task establishes that a later claim will be paid.
| Work or decision | Administrative work | Retained owner |
|---|---|---|
| Request readiness | Check required fields and approved attachments; flag missing or conflicting records | The practice supplies accurate records and approves clinical information |
| Submission and follow-up | Submit through approved channels, record the reference and follow the agreed contact schedule | The client approves submission rules, access and exceptions |
| Clinical questions | Record the payer's request and route it to the named clinical reviewer | The clinician addresses medical necessity, treatment and peer-to-peer review |
| Determination and next steps | Record the payer response, stated limits and open actions; hand back denials or unresolved requests | The payer decides authorization; the practice decides care, scheduling and any clinical appeal |
A submitted request remains pending until its actual status is known. An authorization is not a payment guarantee, as HealthCare.gov's preauthorization definition explains. Keep its dates, service limits and reference available for the later medical billing workflow.
From request intake to a documented handoff
Actigy BPO and the client agree a standard operating procedure (SOP) before live work. It names accepted request sources, required documents, payer channels, follow-up rules and escalation owners.
- Receive the request. Record the planned service, relevant date, payer and source in the approved work queue. Check for an existing request before submitting another.
- Check the inputs. Compare the record with the agreed checklist. Ask the provider for missing documents; do not fill clinical gaps from assumptions.
- Submit under approved rules. Use the permitted payer channel and provider-approved information. Save the submission time and available receipt or reference.
- Follow up and route exceptions. Record payer responses and the next contact date. Send clinical questions, conflicting records and time-sensitive concerns to the named client owner.
- Return the outcome. Record the payer's determination or unresolved status, any stated limits and the next responsible owner. Pass the record to scheduling or billing as agreed.
If a payer asks for more clinical information, the administrative team does not write a medical justification or conduct the clinician's peer-to-peer call. Operators record what is needed and follow up on the handoff. A denial goes back to the client for a decision; any resubmission or appeal handling needs approved instructions.
What a useful authorization record shows
Actigy BPO agrees record fields and a review owner with your team before the pilot. The following is an illustrative review checklist, not a client record or a reported result. Store patient identifiers only in approved systems.
| Record | What the reviewer can verify |
|---|---|
| Intake and readiness | Receipt time, planned service date, required-document status and the owner of missing inputs |
| Submission evidence | Submission time, approved channel and available payer receipt or reference; sent is not the same as approved |
| Pending work | Last response, unresolved reason, next action, follow-up date and responsible person |
| Payer determination | Recorded outcome and source, including stated dates or limits rather than an unsupported summary |
| Handback | The named practice, scheduling or billing owner has the outcome and any open exception |
For example, a new request missing a required provider document should say what is missing and who must supply it. Before it is sent, do not report it as submitted or rejected by the payer. That distinction lets the practice see where action is needed.
During the paid pilot, review record completeness, submission evidence, follow-up against the agreed schedule and correct escalation. Measure administrative handling separately from time waiting for documents or a payer decision. Agree thresholds from the actual queue; no approval rate or universal turnaround is promised.
When prior authorization outsourcing fits
A defined queue is ready to move
Actigy BPO fits recurring administrative work with known request sources, approved payer access and a practice reviewer. A billing company also needs authority under each client's agreement, with records and rules kept separate.
Resolve these blockers first
Missing clinical records, unclear submission authority or no available escalation owner will still stop the work. A queue is not pilot-ready just because it has a backlog.
This is not the right service
The authorization service does not replace a clinician, decide medical necessity or guarantee authorization. It is not an onshore-US staffing offer or a payer software platform. Access restrictions can rule out the delivery model.
For a managed administrative queue, agree daily review and reporting duties. If your practice instead needs another client-directed operator, compare dedicated medical biller staffing. Authorization duties must be assessed separately; the role title does not establish that scope.
Agree access, payer-call hours and escalation coverage
Actigy BPO works on protected health information (PHI) only in client-approved systems. Confirm permissions, work locations, logging, retention and any payer restrictions before access. Review applicable Health Insurance Portability and Accountability Act (HIPAA) requirements and agreements in the written scope and data-processing terms.
Teams in Central and Eastern Europe provide full UK business-day and US morning overlap. Later US payer calls need an agreed shift. Portal availability does not mean a payer representative or your clinical reviewer is available. Name the handoff owner for work that remains open when a shift ends.
Bulgaria, Romania and Poland are in the European Union; Ukraine is outside it. Location is not proof of compliance or permission to process a particular payer's records. Review the broader healthcare operations boundaries before combining queues.
Bring a queue brief, not patient records
Start with a process audit and a paid pilot. For the first discussion, describe the work without patient details:
- Workload: request volume, backlog, planned-service mix and the main causes of incomplete requests.
- Operating rules: payer mix, submission channels, current systems and required call windows.
- Ownership: who approves clinical records, answers exceptions and accepts the pilot work.
- Constraints: permitted locations, access approvals and any deadlines your team must plan around.
The audit sets the included work, review method and handoff rules. Pricing is usually per FTE by role. Confirm supervision, hours, training and retained client work in the quote; this page does not offer a per-authorization price. Expand only after the paid pilot meets the agreed acceptance criteria.
The telehealth revenue-cycle case describes a broader managed engagement combining eligibility, coding, billing, denials and receivables. It is not a standalone authorization-submission study or a payer approval commitment.
The case is anonymized and Actigy BPO-reported, not independently audited. Results depend on scope.
Prior authorization outsourcing FAQ
What does prior authorization outsourcing include?
Actigy BPO handles agreed administrative work: request intake, provider-approved document collection, submissions, payer follow-up and status tracking. Operators work in approved systems and return clinical questions to the named practice reviewer.
The scope defines submission rules, contact windows, record fields and handback duties. A process audit and paid pilot test that workflow before expansion. Clinicians retain care decisions, and payers determine authorization.
Is checking eligibility the same as obtaining prior authorization?
No. Eligibility checks establish what the payer reports about the plan and benefits. Prior authorization is a separate request for a payer determination about a proposed service.
When those tasks are in scope, operators record the requirement and track submissions separately. An active plan does not mean authorization has been obtained. An authorization also does not guarantee payment of a later claim. The practice decides how to handle unresolved requests before care.
Can prior authorization outsourcing guarantee approval or a payer turnaround time?
No. Actigy BPO does not control the payer's clinical criteria or determination. The team can agree measures for administrative handling, record quality, follow-up and escalation during the paid pilot.
Track receipt, complete-document readiness, submission and payer response as separate events. Waiting for clinical records is different from waiting for a payer. A complete submission or prompt follow-up must not be presented as a promise of authorization, payment or a fixed payer response time.
Who handles clinical questions, denials and peer-to-peer review?
The practice's clinical owner handles medical necessity, treatment explanations and clinician-to-clinician review. The administrative team records the payer's request, identifies missing information and routes it to that owner under the agreed escalation rules.
For a denial, the administrative record shows the stated reason and client-approved next step. Operators do not invent clinical evidence, change the care plan or independently choose an appeal strategy. The payer retains authority over its determination.
Can the team follow up with US payers?
Actigy BPO can perform payer follow-up within the agreed authorization scope and working hours. European delivery provides US morning overlap; later US calls need a written shift plan and approved caller access.
Confirm the payer's availability and the practice's clinical escalation coverage separately. Each unresolved request needs a recorded next action and owner at handover. Neither an open portal nor an assigned operator establishes that a payer will respond in that window.
What is needed to scope a paid pilot?
Start with request volumes, payer mix, systems, required hours and the practice's review capacity. Share a description of the queue, not patient records, through the enquiry form.
The process audit confirms approved access, document requirements, submission rules, exceptions and acceptance checks. Live work starts only after the agreed readiness steps. Pricing is usually per FTE by role, with included hours and supervision defined in the quote before the paid pilot.
Scope your authorization queue
Start with the request volume, payer mix and handoffs you need to test.
Review the written scope before deciding on the pilot.
Scope a prior-authorization pilot
What happens next
The team reviews the workflow before proposing a written scope. You decide whether to start a paid pilot after reviewing it.