Medical treatment for some treatments begins only after a provider procures an approval from the patient’s insurance carrier. The process of acquiring this approval is called prior authorization. A prior authorization is usually required when there is a need to carry out a complex treatment or prescription. The process was carried out manually in the past. Today, providers bank on electronic prior authorizations (ePAs) to seek approvals from payers.
Why is Prior Authorization so Complex?
The preauthorization process is complex because of a number of reasons. These include:
- Each payers have multiple and diverse requirements leading to errors and delays.
- Payer and provider workflows are inconsistent
- Payer rules lack standards. It keeps changing constantly.
- Providers are not able to continuously monitor and revise payer rules.
- Payers keep adding to existing health plans to expand their business
- Manual keying in of prior auth requests leads to errors
- Shortage in skilled staff leads to errors that causes delay
- Physician errors because of work pressure.
What are the Negative Effects of Prior Authorization?
An unpredictable preauthorization process invariably throws the administrative workflow into a state of disarray. Many a times practices have to hire or repurpose staff just to deal with piling prior auths needs. This brings a markdown in the performance of the revenue cycle process leading to inefficiencies, additional overhead expenditure, falling margins and over worked office staff.
A delayed or incorrect prior-authorization process can have other ramifications as well. The second biggest impact arguably is delay in patients access to medical care. In the worst-case scenario, it can even compel patients to forego treatment.
An AMA survey on the effects of a delay found that about 75% physicians admitted that patients abandon their treatment. Likewise, 25% of physicians said that a delay has triggered serious adverse event for a patient in their care. It also leads to physician burnout
In some cases, prior authorization cannot be carried out till the treatment gets over. The payer then withholds part, or all of the payment and providers have to bill patients for payments. This strategy leads to lot of delays and may even end up in write offs. The loss incurred has to be absorbed by the practice leading to dwindling profits.
Is it Possible to Speed Up Prior Authorization?
Prior authorization gets delayed for a number of reasons. One of the primary reasons is incomplete information. This leads to a lot of exchange of mails before the process kicks into full gear. Another reason is incorrect information. Most denials are triggered by incorrect submission of information. A few common incomplete submissions include a missing figure in the social security number, transposition of the patient’s health ID card, incorrect spelling of patient name, an address that does not match and so on.
The common reason for errors in claims submissions is overly complicated process with a lot of manual steps in between. Another valid reason is the presence of too many stakeholders in the picture. During the covid most of the incomplete submissions happened because of work overload. Averting them in the first place is the best solution to avoid
However, the most painful aspect of delays is that may happen even if there are no errors from your side. It can happen when there are lengthy medical reviews associated with prior authorization process. The length of the process differs from one payer to another. Any sort of delay in preauthorization introduces uncertainty into the process for both patients and providers.
How to Speed Up Prior Authorization Process
Preauthorization process is slow because most providers use manual methods to process it. Besides causing delays, a slow process also impacts patient outcome. Therefore, adopting ways to speed up the process will make pre-authorization more efficient. Some of the key tactics to speed up the process includes:
- Dedicating a team for prior authorization. The team must consist of trained experts
- Embracing modern-day technologies like medical billing software or electronic prior authorization software.
- Signing up for payer’s newsletters to stay up-to-date with requirements
- Maintaining all prior authorizations information in a central location
- Developing a process for documenting clinical data
- Creating a follow-up plan for successful prior-authorization process. This should be different for different payers.
- Educating patients about prior authorization and all that it entails.
Automating Prior Authorization
Prior authorization involves lot of phone calls and faxes. Besides, it also involves a manual review of papers. This makes the process cumbersome and prone to errors. Therefore, automation is one of the best strategies to streamline the process. Automation significantly eliminates time-consuming processes and improves process accuracy. This translates into maximized revenue.
How Automation Eliminates Time Wastage:
Automating prior authorization helps to automate the following processes:
- Check rules – Map a patient’s health plan with payer rules.
- Procure forms – Pull out payer-specific documentation requirements.
- Make documentation accurate – Incorporate physician order into EHR to meet prior-authorization rules.
- Submit documentation – Fil up payer form as per rules and include all documentation.
- Monitor process – Track submission for approval or rejection. Automate the follow up process when there is a delay.
- Update EHR –Extract information from payer website after approval. Update EHR portals post-approval for compliance documentation.
- Handle rejection – Automate the process of additional document collection in case of denials.
- Automate peer review – Schedule a peer review if documentation requirements are not satisfied.
Benefits of Automating Preauthorization
Some of the benefits of automating the process includes:
- Reduce time for completion of prior authorization process
- Reduction of physician and administration burden
- Real-time data insights about authorization status
- Expedite the process of patient care
- Reduce denials and keep a check on incidence of refusal to pay
- Reduce AR backlog and accelerate cash-inflow through improved first submission success
- Increase higher revenue by getting reimbursed in full for all services provided
- Improve overall practice productivity
Automating the prior auth process is an important step towards eliminating revenue cycle inefficiency. It eliminates all types of operational deficiencies that lead to mounting overhead costs and patient leakage. Many providers prefer relying on software because of the comfort levels involved and the resistance to use advanced technologies. Today, software is an outdated tool as it can only do a single fixed task and must be reprogrammed every time the EHR interface changes. Automated tools on the other hand get integrated with changing EHR interfaces seamlessly and can perform multiple tasks at the same time. It thus frees up health care providers on several fronts and provides them ample room to spend more time with their patients.
Who We Are and What Makes Us an Expert?
This article is brought to you MedBilling Expert a well-known back-office service providers for US-based healthcare practices. We provide support to a range of medical back-office needs. One of the services we specialize in is revenue cycle management. Our sub-services include denial management, eligibility verification, prior authorization, medical coding, medical billing etc. over the years we excelled in providing scalable solutions with the help of technology and experts, to assist large and small practices increase prior authorization approvals, eliminate claim denials and clear aged A/R. Get in touch with us to know more about our services.
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