With the insurance industry unrelenting on reducing or streamlining the prior authorization process, hospitals and healthcare systems continue to struggle with the operational implications of a burdensome and redundant system. It’s time to consider an advanced automation solution that offers real-time processing integrated with the EHR/EMR and billing system. Using artificial intelligence and machine learning capabilities, digital prior authorizations improve patients’ access to care, and relieve clinician frustrations.

It doesn’t matter if your providers have recently completed their training or have been board-certified providers for many years; prior authorizations are a necessary step that simply can’t be avoided. While the symptoms requiring therapeutic intervention are undeniable, insurance companies will require providers to document the necessity of treatment before agreeing to reimburse.

Prior authorizations create frustration in a variety of ways, including:
• Delaying patient care for up to three or more weeks
• Causing a provider to alter their treatment plan for expediency
• Being more susceptible to review and rejection because of insurance company bias
• Being administratively burdensome, taking several hours to several weeks to complete
• Negatively impacting the scheduling process and, ultimately, the patient experience

The American Hospital Association (AHA) recently called on the Centers for Medicare and Medicaid Services (CMS) to improve prior authorizations, stating that they strongly recommended changes that would reduce administrative burdens placed on their membership in their efforts to increase advocacy efforts.

Additionally, the AHA signed onto the American Medical Association (AMA) letter1 expressing strong concerns to the House of Representatives Committee reviewing H.R. 3107, the Improving Seniors’ Timely Access to Care Act,2 meant to streamline and standardize the prior authorization process through Medicare.

While the American Healthcare Insurance Plans (AHIP) group has signed on to support all of the initiatives, insurance payers have been clear that prior authorizations are seen as an effective tool that helps contain costs, and manage the care being delivered and the industry has seen the use of prior authorizations increase, not decrease. According to the Medical Group Management Association (MGMA) 90% of healthcare leaders report that payer prior authorization requirements are increasing with no end in sight.3

While there has been growing discord about prior authorizations for several years with major governmental and industry representative bodies joining the chorus, little has changed. Even if foundational improvements are considered, the prior authorization process will likely continue in a new form, but still, require clinician and administrative time to manage. Being proactive in facilitating an efficient process seems to be the best solution.

The time involved in processing prior authorizations siphons valuable resources away from where it’s needed while business staff process redundant paperwork, sit on hold while waiting for turns, and faxing paperwork all in the hopes of obtaining a quick answer. As documented in the 2019 CAQH Index,4 over 87% of healthcare providers use a manual system that is overly burdensome.

Today, prior authorizations are required for many procedures, tests, and medications throughout healthcare — and hospitals and healthcare systems are no different. Many treatment options all need prior authorizations before the provider can begin to treat the patient. By handling the needed prior authorizations manually, it’s estimated that, on average, over two full days of administrative time per provider are required.

Regardless of the industry stakeholder intention, it doesn ’t appear that prior authorizations will go away completely. Rather it’s more likely that insurance companies will reign supreme, and they will continue in some (hopefully) streamlined form.

No matter how frustrating, prior authorizations do seem to help curb healthcare costs. So the question may be how to make them effective in a hospital or healthcare system setting while reducing the administrative burden/costs and improving revenue? Here are three ways to make the process more functional:

1. Always submit organized, clear documentation

Understanding that insurance will likely question many requests for services, documentation becomes key, including all provider clinical notes.

Implement a protocol or EHR/EMR template that ensures comprehensive documentation. Understand and stay ahead of what they are going to request, making sure to fully complete prior authorizations.

2. Be prepared for clinical review

Most insurance payers will elongate the approval process calling for clinical review or outright reject the request. On the other hand, most insurance payers don’t even require a prior authorization on certain less intensive treatment options signaling their strong desire to funnel patients to that alternative regardless of appropriateness.

Be ready to submit organized, concise, well-articulated appeals with all supporting information. Under the Affordable Care Act, all insurance payers are required to have an appeal process in place. Ask for a 72-hour expedited or urgent review to speed the process along even further.

3. Consider a fully-automated prior authorization process

Engaging advanced automation means using AI-driven software that is secure, comprehensive, and fully electronic. Linked to the EHR/EMR system, prior authorization information can be collected, submitted, and followed up 24/7, in real-time.

When using a fully automated prior authorization system, there is a significant oppor tunity to reduce administrative time and costs, and schedule patients much more efficiently. Should an appeal be neede d, an automated system would generate and submit the appeal based on pre-defined par ameters with associated documentation.

Using up-to-the-minute advanced automation, Prior Authorization Software, that uses ar tificial intelligence and machine learning capabilities, is the most beneficial solution.

To outline, cloud-based, AI-driven software can be integrated bi-directionally with the hospital’s EHR/EMR and billing system. As soon as the patient’s order is input, evaluations, and treatment requiring prior authorizations would be electronically identified, provider/facility detail, patient demographics, and test/diagnosis information would be collected, and an approval request submitted to the insurance payer portal required.

AI-driven software with machine learning capabilities would acce ss continually updated insurance information clearinghouses storing thousands of insurance groups and plans. Each with their own unique guidelines and requirements and electronically determines the prior authorization parameters for routing the request. Prior authorization approvals that once took between a couple of hours t o several days or weeks can now be accomplished in seconds with a 98+% accuracy rate, as documented by an Infinx case study.

Let’s take a focused look at the impact aut omated prior authorizations can have in hospitals: