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 when 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 conducted by Experian Health, 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.”
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
- 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.
- 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.
- 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.
- 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.
- 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
Automation 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 comes better clinical outcomes – and that’s in everyone’s best interest.
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 as 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 Experian Health’s automated prior authorization software helps providers optimize patient care.