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Use automated prior authorizations to expedite patient care

Published: November 29, 2023 by Experian Health

Prior authorizations ensure that patients only receive care that is medically necessary, evidence-based and cost-effective. The process is a built-in safety net to prevent over-prescription of drugs and services, avoid duplication of tests, and make sure that ongoing treatments are actually helping the patient. At least, that’s the goal.

Many providers and patients tell a different story. Too often these well-intentioned mechanisms morph into paper-based barriers to care that do more harm than good in the long term. According to the American Medical Association (AMA), nine out of ten physicians have seen prior authorizations have a negative impact on patient outcomes, while a third have seen authorizations lead to a serious adverse medical event.

A major part of the problem is the growing administrative burden. Processing submissions manually is time-consuming and error-prone – and even more challenging in the context of staffing shortages. Automated prior authorizations can alleviate the pressure and help providers deliver care to the highest possible standards.

How prior authorizations can obstruct patient access and treatment

Health insurers demand that providers seek prior authorization for certain treatments and procedures before they will agree to cover the costs under the patient’s plan. If the request does not meet the payer’s specific rules and criteria, authorization will not be given, and financial responsibility will fall to the patient. If the patient can’t pay, the unsettled sums will find their place in the accounts receivable ledger, eventually written off as bad debt.

To avoid this scenario, patients and providers may decide against the proposed care plan. Findings in the AMA survey suggest that eight out of ten physicians had seen patients abandon treatment because of prior authorizations.

Even where pre-authorizations are eventually approved, the lengthy administrative process to determine whether services and providers are covered can still delay treatment. Such delays cause the patient’s medical situation to worsen, entailing more invasive and costly treatment later. This overutilization of services is clearly at odds with the stated purpose of prior authorizations and the ‘triple aim’ in healthcare.

Manual prior authorizations exacerbate delays in patient care

The problem is compounded by the fact that many providers rely on manual processes to manage prior authorizations. But with payer policies changing all the time, it’s hard for providers to keep up and ensure submissions are accurate. Some procedures need to be approved under one health plan, but not under another, so it’s easy for some to slip through unapproved and wreak havoc later. This is especially worrying for patients with more complex and chronic conditions, who require multiple services from multiple providers. Paper-based processes can be painfully slow, causing bottlenecks in patient care and errors that result in instant rejections when the submission is finally processed. There’s an urgent need for a more efficient approach.

Automated prior authorizations can reduce delays in patient care

Recognizing the need for reform, in December 2022, the Centers for Medicare and Medicaid Services (CMS) proposed a new federal rule that would streamline the prior authorization process for Medicare Advantage plans, Medicaid and Children’s Health Insurance Program managed care plans, and state and Marketplace coverage. If the rule comes into effect, it will require health plans to respond to urgent prior authorization requests within 72 hours, and to non-urgent requests within seven days. Affected payers would need to implement standardized interfaces and automations to improve data interoperability. Further information on this rule may is expected toward the end of 2023. Several states are making their own arrangements to regulate prior authorizations to help alleviate the administrative burden on providers, though these efforts have been described as a “mixed bag.”

Ultimately, improving the prior authorization process comes down to making sure request documentation is filled out and submitted as accurately and as quickly as possible. The most effective way to do that is with the help of automated prior authorization software.

Automated prior authorizations alleviate staffing challenges

Providers are finding increasing value in prior authorization automations as they deal with ongoing staff shortages. In a staffing survey by Experian Health in August 2023, 37% of providers said their prior authorization processes were affected by staffing shortages. Neeraj Joshi, Director of Product Management at Experian Health, says that relying on manual processes in these circumstances is increasingly untenable:

“For many providers, there simply aren’t enough staff to manage the growing burden of prior authorizations. Remaining staff are stressed out, which unfortunately can lead to mistakes and bottlenecks. It creates a poor patient and staff experience. Automating prior authorizations eases the pressure by allowing more authorizations to be processed in less time and making it simpler for staff to track and follow-up inquiries. Not only does a faster approval process mean patients get care without delay, but it also reduces the risk of denied claims.”

Read more about the key benefits of automating prior authorizations.

How it works: key features of prior authorization software

Experian Health’s prior authorization solution, Authorizations, automates inquiries and submissions without user involvement. The software auto-fills payer data based on current requirements, guiding users to any tasks that need manual attention using an exceptions-based workflow. It proactively generates status updates so staff can see at a glance whether a request is pending, denied or authorized.

These integrated automations increase operational efficiency by accelerating the authorizations process, minimizing unnecessary manual work, and reducing the risk of denials. Patients get the care they need, and providers get greater revenue cycle predictability.

Overview of prior authorization platform features

  1. Authorizations accesses current prior authorization requirements in real-time using Knowledgebase, Experian Health’s repository for national payer rules and criteria. Users can add local rules and updates as needed.
  2. Users are directed to the correct payer portal to make a submission for the procedure in question. Documents can be submitted to payers without electronic portals using integrated faxing.
  3. Automated inquiries give users an instant view of whether a submission is pending, denied or authorized. Dynamic work queues alert users to any tasks that need their attention.
  4. Authorization status, number and validity dates can automatically be posted back to health information and practice management systems. Images of payer responses can be stored securely using the integrated document imaging system.
  5. The software compares and reconciles authorized and delivered procedures. It flags any variances to staff can intervene to proactively prevent denials and appeals.

Better communication will lead to better clinical outcomes

Automations may not be able to resolve the conflicting perspectives of over-burdened providers and cost-conscious payers, but they can take the sting out of the administrative process. Prior authorization software smooths out the exchange of data so payers, providers and patients can communicate more effectively. With better communication, come better clinical outcomes – and that’s in everyone’s interests.

A single-vendor solution extends this advantage internally, too. Integrating proven, cost-effective and compliant solutions with existing workflows can help front-end and back-office teams work together as efficiently possible. Experian Health’s Authorizations solution integrates seamlessly with eCare NEXT®, leveraging automations in patient management and revenue cycle workflows, so providers can focus on their core competence: providing high-quality care to patients.

Find out more about how Experian Health’s automated prior authorizations help providers optimize patient care.

Related Posts

Manual prior authorization workflows represent one of the most tedious and expensive aspects of the healthcare revenue cycle. However, despite access to automated prior authorization software, only 31% of providers use electronic prior authorizations, according to the Council for Affordable Quality Healthcare (CAQH). The CAQH predicts that providers who switch to automated prior authorization software could not only gain back valuable staff time, but also see significant cost savings. What is prior authorization and why is it important? In healthcare, prior authorizations are when providers and payers decide in advance if a patient's insurance plan will pay for a specific treatment. Prior authorizations are crucial to reimbursements and keeping revenue cycles on track. Providers that offer services without prior authorization are unlikely to receive reimbursement from the patient's insurer. This can result in unpaid medical bills, leaving billing teams chasing patient collections or writing off bad debt. During the prior authorization process, providers submit a rationale for a proposed treatment to the payer. The request is approved or denied based on certain criteria, including payer policies and medical necessity. The payer may reject a prior authorization request if the treatment or service isn't covered under the patient's insurance plan, if it's not considered medically necessary or if a more affordable alternative is available. Simple paperwork errors, like missed deadlines or incomplete documentation when submitting a prior authorization, may also result in a denial. Challenges of manual prior authorization processes Despite the importance of prior authorizations in the revenue cycle, tedious manual prior authorization processes present challenges for many healthcare providers. Some of the key obstacles providers face using manual prior authorization include: Heavy administrative burden Healthcare providers spend a significant amount of time starting, completing and revising prior authorization paperwork. An AMA survey found that 86% of physicians say prior authorization has increased healthcare resource usage. At the same time, additional AMA data reports that providers spend around 13 hours working on 39 prior authorizations each week, and nearly one-third of providers report that these prior authorization requests usually end up being denied. Changing payer policies Keeping up with multiple payers and ever-evolving payer policies adds strain on staff and ultimately results in prior authorization denials. Changes are often unannounced, making it hard for providers to stay on top of updates. As a result, prior authorization submissions aren’t always accurate and may be based on outdated rules. This can lead to instant rejection and wasted time correcting and resubmitting requests. Inefficient workflows Prior authorization requirements can be complicated, especially when providers are juggling different payers, standards and service lines. Coping with these complexities often puts strain on manual systems, especially when multiple staff and notetaking methods are involved. Staff members may each get different pieces of information from payer websites (or over the phone) and not have the ability to benefit from their shared knowledge efficiently. Navigating communication hurdles and rapid payer information changes can result in workflow inefficiencies that snowball quickly. How prior authorization software can improve efficiency Replacing manual prior authorizations processes with automated prior authorization software can help providers improve efficiency. Here are some key ways providers benefit from automated prior authorization solutions, like Experian Health's Authorizations. Reduces manual interventions: This solution limits guesswork, human errors, and misinterpretations by automating data originating from the EMRs. Automation saves staff time and energy and prevents frustration. Stays current with latest payer policies: The prior authorization system stays up-to-date with the latest regulations and payer requirements. Automatic updates provide staff with the most current information, eliminating the need for staff to visit multiple payer websites or cross-check data by hand. Provides real-time updates: Providers can promptly clear authorizations for service by proactively identifying authorization status as pending, denied or authorized. This allows physicians to make timely treatment plans and for patients to avoid disruptions in care. Reduces risk of denials: Through automation, electronic prior authorization software ensures the accuracy and completeness of submissions by automatically checking with payers and vendors to validate that the authorization is on file. Payers and providers also get a shared view of account information, reducing the need for prolonged discussions about the status of authorization and rework requests. Key features to look for in prior authorization software When implementing prior authorization software, look for a solution that offers a wide range of features to automate and streamline the prior authorization process. Experian Health's prior authorization solution, Authorizations, for instance, offers healthcare providers the following key features: Real-time knowledgebase: Access to up-to-date prior authorization requirements and criteria in the National Payer Rulesets Submissions support: Removes guesswork and directs users to the correct payer portal based on procedure Automated inquiries: Automates the prior authorization payer inquiry process Enhanced workflow: Dynamic work queues display status and guides users through next steps Postback: Allows users to easily send authorization status, number and validity dates to health information systems (HIS) and practice management systems (PMS) Image storage: Receives and securely stores payer responses in an integrated document imaging system Reconciliation: Provides insights into authorization variations and helps resolve them, so staff can take proactive steps to prevent denials and appeals Integration with electronic health records and billing systems: Why it matters Providers often choose a prior authorizations platform that seamlessly integrates with existing Electronic Health Records (EHR) and billing systems for maximum efficiency. Solutions like Experian Health's automated prior authorization management tool, Authorizations, easily adapt to existing processes. This eliminates the need for a complete workflow overhaul and minimizes the learning curve for staff. Embracing prior authorization software for a more efficient revenue cycle Revenue cycle leaders who implement prior authorization automation strategies could see significant savings – $494 million annually as an industry, according to CAQH data.  Claims and revenue management processes are often complex and outdated, costing healthcare organizations time and money. High denial rates and slow reimbursements can hurt cash flow and get in the way of financial stability. Automating prior authorization can reduce claim denials, speed up reimbursements and improve the bottom line. Learn more about how Experian Health's electronic prior authorization software, Authorizations, uses automation to achieve greater consistency and efficiency for healthcare organizations. Learn more Contact us

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