A Solution for the AMA Prior Authorization Reform

By Infinx
April 1, 2019

One could argue that the Hippocratic Oath taken by physicians around the U.S. has been tested by current prior authorization programs that place cost savings ahead of optimal care. Given the potential barriers that prior authorization can pose to patient-centered care, a coalition led by the American Medical Association (AMA), which includes 16 other health care organizations, urged an industry-wide reassessment of these programs to align with a newly created set of 21 principles in 2017.

In its treatise, “Prior Authorization and Utilization Management Reform Principles,” the coalition asserts that prior authorization programs could be improved by applying common-sense concepts grouped in five broad categories: 1) Clinical Validity; 2) Continuity of Care; 3) Transparency and Fairness; 4) Timely Access and Administrative Efficiency; and 5) Alternatives and Exemptions.

Infinx’s Prior Authorization Software is a solution that quickly and effectively solves for 100 percent of prior authorization delays and denials, saving money, eliminating unnecessary adverse patient outcomes, and serving as an important tool in the AMA-led coalition’s movement to reform the healthcare industry. Here are just a few of the ways that the Infinx Prior Authorization Software can contribute to the transformation.

Clinical Validity

The data entry and administrative tasks associated with prior authorizations reduce the time available for patients. According to an AMA survey, more than 90 percent of physicians reported prior authorization requirements had a negative impact on patient clinical outcomes and those prior authorization procedures held up patient access to necessary care.

In short, these delays and denials are negatively affecting the health of patients in a significant and measurable way. While a coalition led by the AMA launched a campaign to reform prior authorization requirements in 2017, little has been accomplished. However, one tactic that everyone can agree on is an industry-wide adoption of an automated prior authorization solution such as the Infinx Prior Authorization Software. AI optimizes your patient access workflow and with our exception handling by trained and certified prior authorization specialists providing you with complete coverage, preserving your revenue before appointments.

Continuity of Care

It goes without saying that unanticipated changes to a formulary or coverage restriction throughout the plan year can negatively impact the patient experience and potentially the outcome. One way to mitigate this problem, the coalition asserts, is to ensure that a prior authorization approval is valid for the duration of the prescribed/ordered course of treatment.

In terms of prior authorization determinations and RCM, few organizations possess Infinx’s extensive knowledge base of payer policies, guidelines or the vast knowledge of rules learned using advanced machine learning techniques employed on a vast repository of payer authorization outcomes.

Infinx’s Prior Authorization Software is the most agile solution available. It is easily capable of being adapted to ensure that prior authorization approval is valid for the duration of the prescribed/ordered course of treatment.

Transparency and Fairness

Prior authorization requirements can have a direct impact on patient care by creating a delay or altering the course of treatment. In order to ensure that patients and health care providers are fully informed while making care decisions, the coalition calls for utilization review entities to make statistics regarding prior authorization approval and denial rates available on their website (or another publically available website) in a readily accessible format.

The statistics would fall into categories related to prior authorization requests including health care provider type/specialty; medication, diagnostic test or procedure; indication; total annual prior authorization requests, approvals and denials; Reasons for denial such as, but not limited to, medical necessity or incomplete prior authorization submission; and denials overturned upon appeal.

To achieve this ambitious principle, a standardized electronic prior authorization transaction would have to be adopted. Infinx’s Prior Authorization Software provides exactly the type of transparent datasets called for by the coalition to save patients, providers and utilization review entities significant time and resources and can speed up the care delivery process.

What’s more, the proprietary AI engine in Prior Authorization Software learns and improves from all data and interactions to provide ever-smarter, more efficient product. The engine also has the capability to be integrated to any EMR or practice management system through an API which can offer a fully transparent window into real-time results.

Timely Access and Administrative Efficiency

In order to ensure that patients have prompt access to care, the coalition asserts that utilization review entities need to make coverage determinations in a timely manner as “lengthy processing times for prior authorizations can delay necessary treatment, potentially creating pain and/or medical complications for patients.”

Furthermore, if a utilization review entity requires prior authorization for non-urgent care, the entity should decide and notify the provider within 48 hours of obtaining all necessary information and 24 hours of obtaining all necessary information for urgent care.

The coalition also encouraged these entities to standardize criteria across the industry to promote uniformity and reduce administrative burdens.

Infinx’s scalable platform intelligently automates many of your patient access and RCM processes, creating timely access and efficient administrative processes. It provides the fastest turnaround times in the industry and is highly customizable to conform to any standards.

Despite the AMA’s best efforts, the coalition’s call has failed to produce a significant impact on the very complex and thorny issue of prior authorization reform. The good news is that Infinx’s Prior Authorization Software will not only be a big part of the industry’s impending transformation, but it is available to you today.

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About the Author

Infinx

Infinx

Infinx provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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