What is prior authorization?
Prior authorization, often abbreviated as PA, is a process used by insurance companies to determine if they will cover a prescribed medication, procedure, or service. It serves as a safeguard to ensure that treatments are medically necessary, evidence-based, and cost-effective.
Why is it necessary?
The primary purpose of prior authorization is to control costs and promote appropriate healthcare utilization. By requiring authorization before certain services, insurers aim to prevent unnecessary procedures, reduce overutilization of resources, and ensure patient safety.
However, despite their intended purpose, these processes can sometimes become barriers to care rather than facilitators. Let’s delve deeper into how prior authorizations impact patient access and treatment and explore the benefits of automated solutions in alleviating these challenges.
Challenges with traditional prior authorization methods
Impact on patient outcomes
According to the American Medical Association (AMA), prior authorizations often have a detrimental effect on patient outcomes. Physicians report that these requirements can lead to delays in care and even serious adverse events.
Administrative burden
Manual processing of prior authorizations is time-consuming and prone to errors, especially amidst staffing shortages. This administrative burden can impede healthcare providers from delivering optimal care to their patients.
Obstructing patient access and treatment
Health insurers frequently require prior authorization for specific treatments and procedures. Failure to obtain authorization can leave patients responsible for covering the costs or result in treatment abandonment. Moreover, even approved authorizations can lead to delays in care, worsening the patient’s condition.
The case for automated prior authorizations
Streamlined processes
Automated prior authorizations offer a solution to the inefficiencies of manual methods. By automating the submission and approval process, these systems reduce administrative burdens and expedite patient care.
Regulatory changes
Recent regulatory efforts, such as the proposed federal rule by the Centers for Medicare and Medicaid Services (CMS), aim to streamline prior authorization processes. These initiatives mandate quicker response times from health plans, promoting standardized interfaces and data interoperability.
Benefits of automated solutions
Improved efficiency
Automated prior authorizations enable faster approvals, minimizing delays in patient care. By reducing manual work and error rates, these systems enhance operational efficiency for healthcare providers.
Staffing challenges
With ongoing staff shortages affecting prior authorization processes, automation offers a viable solution. By relieving staff from manual tasks, automated systems mitigate the risk of errors and ensure timely approvals.
Key features of prior authorization software
Real-time access to requirements
Software solutions like Authorizations provide real-time access to payer rules and criteria, streamlining the submission process for healthcare providers.
Automated inquiries and submissions
These systems automate inquiries and submissions, reducing the need for manual intervention and expediting the authorization process.
Integration capabilities
Integration with existing healthcare systems allows for seamless communication and data exchange, facilitating better coordination between payers, providers, and patients.
Enhancing clinical outcomes
While automation may not resolve all challenges in the healthcare landscape, it can certainly improve communication and streamline administrative processes. By optimizing prior authorization workflows, providers can focus on delivering high-quality care and achieving better clinical outcomes for their patients.
Automated prior authorizations offer a promising solution to the challenges faced by traditional manual processes. By leveraging technology to streamline workflows and improve efficiency, healthcare providers can enhance patient care and optimize resource utilization.
Experian Health’sAuthorizationssolution integrates seamlessly witheCare 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 Experian Health’sautomated prior authorization softwarehelps providers optimize patient care.
