Through the process of cost containment and utilization review, the healthcare industry has taken an already complex and burdensome system and added a layer of administrative oversight that has created patient access issues as well as adding to the immense physician burn-out problem. While this process has been growing for some time, it seems to have reached a tipping point when the American Medical Association (AMA), along with 17 other healthcare stakeholders published a set of guidelines meant to improve payer prior authorization (PA) programs.
In this set of principles, the AMA tried to apply common sense to issues such as continuity of care, transparency and fairness, patient access, and administrative efficiency. They further noted that over 75% of surveyed physicians rate the burden of PAs as high or extremely high, while 90% stated that PAs often delay patient care up to and including treatment abandonment.
What Can You Do to Improve Patient Access to Care?
To be clear, insurance payers will likely continue to require PAs to substantiate need and to control costs for the foreseeable future. So what can your organization do to alleviate some of the administrative costs and burden, and more importantly, streamline the process for your patients?
Here’s a look at three ways you can ensure timely patient care:
1. Check Requirements for PAs Before Submission
Ideally, every insurance payer would have the same PA protocols, and every patient would have similar treatment plans and health histories. But that is simply not the case in healthcare today. So whether your providers are recommending surgery, prescribing a formulary exception, or requesting an advanced diagnostic test, it’s worthwhile to determine PA requirements in advance of treatment.
At the very least, this reduces denials for unmet requirements and should correspondingly increase reimbursement. Unfortunately, staying up to date on this information can be laborious and gleaning changes and updates from payer newsletters and bulletins is exhaustive.
2. Establish a Consistent Protocol for Documentation in the EHR/EMR
PAs almost always require provider documentation to be submitted in support of the corresponding medical necessity. Establishing a consistent protocol for this process speeds along the documentation to be matched up with the correct PA and lessens the administrative burden of chasing down missing or misplaced documentation.
3. Automate the PA Process Using Automation and Artificial Intelligence (AI) Driven Software
As recent as April 2019, the Council for Affordable Quality Healthcare (CAQH) noted that 90% of all PAs are handled manually through phone and fax—that’s over 77 Million PAs per year! By automating this workflow, your organization would be able to determine if a PA is needed, gather and submit the required information, follow-up on outliers, and forward completed PAs directly to the scheduling department in real-time.
With a fully integrated solution, your patients would get their appointments scheduled faster and move through the care continuum more smoothly. This would further reduce provider frustration and bring more revenue to the bottom line with reduced denials and rework.
While the AMA’s stakeholders guidelines have made it all the way to Congress and the Committee on Small Business, any significant change to the insurance payers’ requirements will be slow to arrive (if they do at all). A more prudent and long-term solution would be to streamline the PA process using automation and AI-driven software, supported by certified specialists to expedite PAs needing specialized handling, such as emergent requests or unforeseen problems.
Contact us today to schedule a demo to learn how we can maximize your revenue payment lifecycle.