In 2018, a group of organizations issued a consensus statement that targeted the need and the goals for improving the prior authorization (PA) process. These organizations and their leadership, consisting of physicians (AMA, MGMA), pharmacists (APhA), hospitals (AHA), and insurance payers (AHIP), agreed to take a collaborative approach to improve the PA processing system industry-wide.
Revisiting this issue and observing the progress made is less than satisfying and may not change significantly any time soon. While there is a strong payer commitment to PA improvement with 96% of payers stating they are in a cooperative stance, an ever-increasing number of providers say the burden has only grown.
Can Automating Prior Authorizations be a Solution?
To state clearly, according to the MGMA 2019 survey, 90% of responding providers say that the PA burden has grown in the last year. On the flip side, as many as 88% of PAs are completed (either partially or entirely) using a manual workflow. This means untold hours of hold times, faxing, and follow-up that equates to an average of 14.9 hours (or two business days) per provider.
What’s to be Gained?
By introducing automation to the PA process, hospitals and providers stand to gain exponentially in terms of the following:
- Reduced patient frustration and potential abandonment of care
- Administrative focus moved from payer PA regulation compliance to patient experience and higher value efforts
- Potential reduction in claim denials
- Increased revenue and operational bottom-line results
- And maybe most importantly, reduced physician burnout and early retirement, and increased interest in healthcare provider career options to combat the severe shortage materializing currently
How Does Automation Change the PA Process?
When examining the administrative workflow, it becomes clear that Artificial Intelligence (AI) and machine learning software can actively absorb much of the routine, repetitious functions when filtered through a continually expanding clearinghouse of payer criteria. Ideally, the process would advance as such:
- Once a patient’s treatment plan and payer eligibility has been gathered and verified, a needs determination would assess insurance requirements
- If a PA is required, automated submission would be initiated and followed-up through a bi-directional, seamless portal integrated with the provider’s EHR/EMR system
- Scheduling personnel would be notified electronically when the PA was approved reducing the need for rescheduling and inconveniencing patients
- Automated follow-up and status checks in real-time would ensure no patient falls through the cracks
- And because AI isn’t an end-all solution nor does it operate in a vacuum, certified specialists (human intelligence) would actively engage and submit PA requests that were emergent or needed special handling
While the wheels continue to grind on healthcare PA reform, let’s not forget that the primary reasons that utilization management and PAs were instituted are still very valid and worth pursuing — solid, necessary medical care that is cost-effective. By removing the administrative burden, as well as the feeling of having to ask for permission, through automation and real-time approvals, providers and patients can focus on the healthcare decisions that are the reason for the process in the first place.
Contact us to discuss state-of-the-art AI-driven prior authorization technology and support and certified specialists.