When it comes to the least supported aspect of the healthcare billing lifecycle, prior authorizations are #1. Long seen as unnecessarily disruptive and burdensome, prior authorizations have been around for years as an offshoot of utilization management. Since 1995, they have been the healthcare insurance industry standard for monitoring costs and controlling access.
Anything but welcome prior authorizations are seen as a significant practice and hospital burden, as evidenced by a report from the American Medical Association (AMA) where 92% of physicians reported that prior authorizations often delay a patient’s access to essential care. And while there has been progress in consensus building industry-wide, real change may take years and amount to very little. Some even speculate that shifting reimbursement models, i.e., value-based care may actually bring more oversight, not less.
Searching for a Proactive Solution
When onboarding a patient, the process needs to be smooth, time-sensitive, and efficient. Today’s consumers are tech-savvy and want convenient access to care; a several-hour, or several-day, wait for insurance authorization is something that denigrates the patient’s experience and reflects poorly on the organization.
Outsourcing Technology and the Human Factor
Looking for a third-party partner to come in and process the prior authorizations the same way has always been futile. With 88% of prior authorizations being processed manually, the expense and inefficiency would only shift outside. Still, they wouldn’t improve the accuracy, reduce the claim denials, or improve the patient’s encounter with the organization.
The key is to bring advanced automation using artificial intelligence (AI) and machine learning capabilities, coupled with highly skilled specialists to process complex or emergent claims. With such a system in place, prior authorizations could be executed and approved in real-time, allowing patients to be scheduled quickly and efficiently, reducing visits from care abandonment.
Evaluating and Implementing Outsourced Prior Authorizations
When making a major investment in technology and potentially impacting jobs and workflow, it’s important to be thoughtful and deliberative in the process involving all stakeholders that have an interest in the outcome. Consider these issues:
- Explore and Evaluate the Desired Endpoint — The goal is to develop the plan and the roadmap on how to get there. What level of technology, analytics, or scalability best suits the organization? Where are the positives and negatives? How much improvement can the bottom line expect?
- Survey All Options to Determine the Best Solution — Remember, it may feel like you are giving up some level of control, but for what advantages. By eliminating or revising the PA process internally, you will be making it significantly more efficient for patients and freeing up staff members for higher-level functions.
- Selecting the Best Third-Party Partner — This relationship benefits from multi-layered collaboration and requires an organization with real-life business process experience, as well as a proven track record of successfully executing their vision. Not only does there need to be trust, but also a deep understanding of the technology and the complexities of healthcare’s third-party payer system.
- The Ability to Quickly Deploy — Find a third-party partner that can rise to any occasion with scalability and leave the training, hiring, and managing of staff to someone else.
- The Flexibility of the Technology — Are you selecting advanced automation tools that can integrate with the existing EHR/EMR/RIS/LIS or other verification or compliance instruments or programs? Can it adjust or adapt as technology changes and requirements from insurance companies expand or contract?
- Monitoring Real-time Results — Can analytics be provided 24/7 to monitor results, and ultimately improve customer satisfaction?
Today, there are solutions that can greatly enhance the prior authorization process and, thereby the patient experience. By reducing the internal costs and inefficiencies to workflow, you are no longer reliant on promised improvements that never seem to materialize. Removing the frustration brought by the entire prior authorization process while complying with contractual agreements is a proactive solution that eases the onboarding process for patients and ensures that they get the care they deserve.
Learn more about our ability to bring automated prior authorizations with experienced specialists to your organization to significantly improve the patient’s onboarding experience and provide you with full prior authorization coverage.