By Christa Lassen-Vogel, Senior Manager, ZOLL Data Systems
The prior authorization (PA) process healthcare providers endure is a story of unintended consequences. Created as a utilization management tool for healthcare insurance companies to control costs and protect patients from surprise bills, it has unintentionally created heavy administrative burdens, increased claim denials, rework, and delays in patient care. PA process challenges have a negative impact on providers’ financial performance and cause unnecessary stress for billing teams and patients alike.
Addressing the root causes of process delays, administrative bloat, and claim denials that lead to write-offs is complicated — especially with increasing PA demands from payers. Rules differ from payer to payer and from plan to plan, and the rules change frequently. Typically, the process is highly manual and requires administrative staff to search paper documentation, PDFs, and payer web portals. Physicians and other providers must review the PA requests and medical charts, robbing them of time — up to 16 hours per week, according to some reports — that could be spent with patients.
If PA is required, providers must track down specifics pertaining to each current procedural terminology (CPT) code applicable to the prescribed treatment. They also must obtain a number, assigned by the payer, that corresponds to the PA request and include it when the final claim is submitted. The responsibility falls on the provider to continue to follow up with the payer until there is resolution of the request — an approval, redirection, or denial. Depending on the complexity, the level of manual work involved, and the requirements stipulated by the payer, a PA can take anywhere from one day to a month to process.
Delays Hurt Patients, Providers, and Profits
PA delays can cause problems for both patients and for the providers attending to them. Some patients may forego treatment or fail to adhere to prescribed medication. Furthermore, delays can cause unintended consequences that add to the cost of care. Patients may experience an adverse event and seek interim treatment at an emergency department while the PA is under review.
The burdensome PA process robs providers and the administrative team that supports them of time that would be better spent attending to patients. The unpredictable process disrupts workflows and hurts administrative efficiency, adding to overhead costs.
Sometimes, PA requirements are not determined until after treatment is complete, resulting in partial or no reimbursement. When that happens, providers must try to collect payment directly from patients, a process that may mean writing off uncollectible patient balances as bad debt.
Real-time PA Technology Can Streamline the Process and Alleviate Administrative Burden
Fortunately, there is technology that can dramatically improve the PA process and give doctors back those hours to spend on patient care. Implementing tools that automate manual tasks can reduce the administrative burden, improve financial performance, and serve patients better with timely care and a more frictionless experience.
With the number procedures requiring PA expected to grow, finding a way to mitigate tedious, time-consuming, manual tasks through automation is urgent. Best-in-class PA tools leverage artificial intelligence (AI) to automate much of the process in real time, eliminating the need for faxes, phone tag, and emailing.
Building upon automated eligibility and patient financial responsibility systems, providers can add AI-enhanced, real-time PA technology to drive the PA process as early in the revenue cycle as possible. Doing so reduces the likelihood for errors, slashes manual work wasted on tedious tasks, and accelerates patient care. It also adds invaluable functionality, such automatic identification of whether PA is required and determination of the optimal submission route.
A fully integrated, end-to-end approach includes:
- A master patient index (MPI) that can identify each unique patient
- Direct, real-time connections to most payers
- An extensive library of payer rules that synchronizes eligibility and PA rules
- Integration with workflows and systems like EHR, LIMS, health information system (HIS), and revenue cycle management (RCM) solutions
- A self-learning system that uses artificial intelligence (AI) to dynamically update automated workflow and rules engines based on the actual responses and results from submitted PAs
- Ability to integrate with automated revenue optimization tools, such as demographic verification, insurance discovery and verification, self-pay analysis, and deductible monitoring
- Ability to validate a PA request against payer guidelines, automatically submit it, and then receive instant decisions from the payer.
By streamlining the PA workflow, patients can access care faster, with the added benefit of understanding and planning for their out-of-pocket financial responsibility. They may also reduce or prevent hospitalizations that could add significant, additional expenses.