Long a problem in healthcare providers day-to-day operations, prior authorizations (PAs) have seemed impervious to legislative intervention or industry association calls for reform. They seem redundant in the value-based care process by their nature, but seemingly find no support for change or abbreviation.

While there is a consensus among hospitals and providers that PAs are burdensome and a waste of resources, it appears that – at least for now – they are here to stay.

Managing Prior Authorizations for Results

So what is the best way to manage a process that is steeped in repetition and manual inefficiencies? First, it would make sense to review the entire process from the initial encounter between the patient and the provider through the business office protocol to obtain an approval.

We know that at least 87% of providers use a manual system to process and follow-up on the PAs. According to the 2019 CAQH Index – Conducting Electronic Business Transactions, only 13% of healthcare participants are using advanced automation solutions available today, which means that the vast majority are still using phones, faxes, and other outdated manual modes to transmit their requests to insurance payers. This potentially adds hours that would be better deployed toward higher valued functions like patient care.

4 Answers Available Right Now!

  1. Monitor insurance health plan newsletters, bulletins, and updates for changes — Done manually, this can be cumbersome. However, insurance payers are notorious for releasing information haphazardly, and any changes issued can have a significant impact on patient care.

    Another approach would be to use automation and AI-driven software that learns from insurance payer plans and can determine whether a PA is required or not in near real-time. As new payer guidelines are released, machine learning allows the system to incorporate the new parameters.

  2. Establish protocol and/or templates with the EHR/EMR/RIS/LIS to capture all appropriate information early and accurately. There are some inherent challenges since insurance payers have different protocols and unique forms to fill out. The administrative team responsible for processing PAs needs to be agile and flexible to stay abreast of changes.

    Using an advanced automation solution, PAs are initiated in near real-time using and forwarded electronically to the appropriate insurance payer. For emergent or outlying requests, a team of experienced specialists can focus on submission, follow-up and completion, providing you with complete prior authorization coverage.

  3. Follow-up regularly to proactively address any issues that may arise. PAs can be held up for any number of reasons, and it takes active participation to monitor and respond in an ongoing fashion or risk losing the PA in the system.

    Enlisting the help of advanced automation means that follow-up is occurring electronically with requests submitted repeatedly 24/7 until completion.

  4. When PAs are denied, have a deliberate, concise appeal process that ensures all supporting clinical documentation is attached before submission. —- In an automated environment, the appeal process would be activated electronically, generating an “action required” notification. Necessary documents are then pulled from the EHR/EMR/RIS/LIS system, and the case is resubmitted. If that has already been done, then the appeals process would be initiated.

It doesn’t look like PAs are going to be drastically altered any time soon, and insurance payers continue to have expectations that tests and procedures requiring PAs will only increase in the future, not decrease.

Now is the time to invest in an automated PA solution; Infinx’s Prior Authorization Software has a >98% accuracy rate and can significantly reduce the time involved in processing your PAs. With fewer denials and a more efficient process, your practice would also capture more revenue.

Contact us to set up a demo of our Prior Authorization Software today and see how we can reduce denials and improve your patient access workflow.