by Marcia Leighton, Executive Director Client Services
Although healthcare providers and health plans want to ensure patients receive the care they need, obtaining prior authorizations continues to be a thorny process. U.S. healthcare has a complex payer system consisting of perpetually shifting rules that vary from payer to payer making obtaining prior authorizations a significant burden for providers, staff, and patients.
According to the 2017 AMA Prior Authorization Physician Survey physicians and staff spend an average of more than 14 hours completing 29.1 prior authorizations each week. The time demands are due to many factors including payer inconsistencies, inefficient workflows, lack of or siloed technology, and the added complexities of the involvement of multiple entities.
Payer coverage criteria vary by payer and often change making it difficult to keep up with the most current regulations. Although patient access staff typically initiate prior authorizations, physicians, nurses, revenue cycle management (RCM), and patient financial services teams can also be involved in the process. Additionally, healthcare staff engages with payer utilization management departments and third-party medical benefit management (MBM) companies who conduct clinical reviews.
Many hospitals utilize separate systems for electronic health records (EHRs) for clinical data and financial billing data leading to disjointed workflows. The lack of a seamless workflow many times requires staff to rekey clinical data to request a prior authorization. This leads to not only the potential for human error but added staff time and cost. The 2019 Council for Affordable Quality Healthcare (CAQH) Index indicates prior authorizations are the most costly and time-consuming transactions to conduct manually reflecting a growth rate of 27 percent from 2016 to 2018.
Prior Authorization Patterns and Commonalities
For prior authorization management to be efficient, cost-effective, and timely, it is essential your prior authorization processes can detect patterns and commonalities between requests. As an example, one payer may require prior authorization for a procedure with a specific diagnosis that another payer does not.
These payer patterns and commonalities should be well documented and easily referenced by staff. Comprehensive payer documentation must comprise of a common rules repository identifying the payers’:
- Prior authorization requirements and when a procedure code tool identifying when prior authorization is required is available
- Prior authorization processing timeline
Payer rules, timelines, and policies can ensure prior authorization is obtained efficiently and without a delay in care. With payer rules clear and easily accessible, prior authorization teams can identify potential delays and address issues at pre-access.
Automation is Key
There are many opportunities for improvement when it comes to prior authorization and although comprehensive payer knowledge is important, automation is key to minimizing the time and costs associated with prior authorization. CAQH research shows that fully electronic prior authorizations take just four minutes to complete, reflecting nearly 80% improvement compared to manual processes. Operational efficiencies increase 65% or more, a cost reduction of up to 75%, and denials are reduced by 50%. These metrics reflect a boost in revenue recovery and reduction in the administrative burden that frees up providers to focus on the care they provide their patients.
Through automation, prior authorization processes can be standardized and streamlined to accelerate time to authorization as well as accuracy. Automation can identify plan-specific payer requirements in real-time and alert staff. Staff is guided through each payer’s submission process – automatically checking and rechecking the authorization request status, alerting users when additional information is needed, and immediately reporting approvals and denials. By using HL7 standards, a reliable method of tracking prior authorization requests via EHR work queues or shared documents can be set in place and data entry can be eliminated resulting in reduced errors and time. Additionally, through machine learning and AI technology past outcomes are identified and workflows can be adapted based on learned insights.
The Road Forward
The objectives of controlling costs and ensuring appropriate care are valid, but handling prior authorization manually is unsustainable for many providers. The solution to the most pressing prior authorization roadblocks is automation. Although many healthcare providers lack the technology, time, and expertise to implement electronic processes, the financial repercussions of the COVID-19 pandemic shed light on the dire need to move prior authorization into the age of technology for the good of everyone from insurance payers and healthcare providers to patients alike.
Although end-to-end prior authorization management is the ultimate goal, automating parts of the authorization process can also be beneficial to providers and patients. For instance, determining whether or not the prior authorization is required through automation can reduce workload allowing staff to focus only on cases that require authorization. By tackling prior authorization one piece at a time, providers can begin building their path to efficient and effective prior authorization management.
Want to learn more?
Check out how PatientMatters Prior Authorization Management solution helps healthcare providers increase productivity and reduce denials while enhancing patient satisfaction.
