The call for streamlined prior authorization and utilization management reform has been growing louder and more intense, so why has there been little movement? Aside from the resistance of insurance payers who stand by their process, there are physical and technical challenges precluding the complete automation of the prior authorization workflow.

However, 2020 brought new hardships and headaches that will further complicate patient access and automated prior authorizations in 2021 and beyond:

  • COVID-19 has created a lasting impact on our society and on the healthcare industry. New safety guidelines and telehealth-specific care mandate fewer patients in the office. Additionally, patients are foregoing care due to concerns over finances or physical safety. With practice viability often directly associated with volume, these new realities are causing office closures and staff layoffs that will continue into 2021.

  • For physician practices, this reduction in volume has directly affected planned implementation of automated prior authorizations. Financially, they simply have to postpone improvements until they can regain viability.

  • Expanding Medicare populations bring more utilization review and management. The Medicare population is expected to grow from 44 million to 79 million by 2030. With the growing number of people moving to Medicare, utilization management and prior authorizations will be increasing to manage the amount of care provided.

  • The use of accumulators and maximizers directly affects patients hoping to use pharmaceutical company patient assistance programs for needed medications. Insurance payers and pharmacy benefit managers are using these programs to shift this monetary support away from co-pays and deductibles negatively impacting patients.

Calls for Change

In early 2018, healthcare stakeholders took a more proactive stance in pressuring the Centers for Medicare and Medicaid Services (CMS) and commercial insurance payers to overhaul the prior authorization process. The efforts have picked up steam in light of the COVID-19 public health emergency. The American Medical Association, joined by 16 other groups, participated in a joint task force with the sole purpose of developing reform principles to guide a streamlined prior authorization process and reduce friction.

While the original intention set by utilization review and prior authorizations was a good one, the mechanics of administering them has created a cumbersome and unnecessarily awkward process with frequent denials and patient care issues. The recently released 2019 AMA Prior Authorization Physician Survey notes that almost 90% of physicians report that patient care is negatively affected and often results in delays in patient care and abandonment.

Current Prior Authorization Process: Manual vs. Automated

According to the 2020 CAQH Index on “Closing the Gap”, 79% of medical practices use a manual system to manage prior authorizations at a system-wide cost of $13.30 per prior authorization.  Add to that the unworked claims denials experienced from missing or rejected prior authorizations, and the costs are astronomical.

Now compare that to the savings and efficiencies available through an automated system, and prior authorizations become much more palatable and manageable to gauge quality and appropriateness of care.  On a system-wide basis, automated prior authorizations, using augmented intelligence, would achieve the originally intended consequences and improve the patient’s experience and the practice’s bottom-line.

The bottom line is that total electronic processing, including artificial intelligence (AI) and machine learning capabilities, is an incomplete answer.  There needs to be an augmented intelligence solution that marries automation and human intellect to realize the goal of efficient prior authorizations fully.

“Artificial Intelligence constitutes a host of computational methods
that produce systems that perform tasks normally requiring
human intelligence. However, in healthcare, a more appropriate term is
‘augmented intelligence,’ reflecting the enhanced capabilities of human clinical
decision-making when coupled with these computational methods and systems.”
-American Medical Association

5 Challenges Preventing System-Wide Adoption

In August 2020, CMS announced the Adopted Standards and Operating Rules where HIPAA required HHS to establish national standards for electronic transactions, defining the adopted standard for prior authorizations as ASC X12N 278 Version 5010 (Phase V of the CAQH CORE findings as the HHS-designated Operating Rule Author).

While this is a significant step, there remains five industry-wide challenges to fully automated prior authorizations, as outlined in the CAQH CORE’s report entitled “Moving Forward: Building Momentum for End-to-End Automation of the Prior Authorization Process.”

1. Lack of Data Consistency Throughout the Industry

There is a lack of uniformity between insurance payers in the coding used to communicate status, errors, and next steps. Requirements differ amongst plans and create confusion for providers trying to submit critical information in their requests. In turn, this has been a challenge for automation developers, as they try to match intent with payer requirements.

2. Lack of Mandated Standards for Clinical Documentation and Other Required Attachments

From payer to payer, there is a shortfall of standardization and uniformity across plans for attachments and clinical documentation resulting from individual payer proclivities. Vendors have found it difficult to create solutions that support HIPAA’s electronic standard for prior authorizations, thereby resulting in numerous side steps to reach compliance.

3. Lack of Clinical and Administrative System Integration

Historically, there has been a lack of integration between EHR/EMR and practice management systems, creating barriers to providing an automated prior authorization solution.

4. Lack of Consistency in State Requirements

Legislatively, several states have mandated that insurance payers notify providers by phone or USPS mail when there are outliers, such as complex prior authorization approvals and rejections. For instance, in Minnesota, payers must contact providers when a prior authorization is not approved. In Colorado and Rhode Island, providers can speak directly to a qualified medical representative when there is an adverse determination.

5. Lack of Provider Awareness

Providers are unaware that HIPAA requires health plans to offer the 5010X217 278 Request and Response solution for prior authorizations. While, as stated above, CMS is actively spreading the word about the requirement from HIPAA compelling health plans to accommodate the technology, it will take a proactive push from provider organizations to fully engage their constituency and demand compliance.

So, What’s the Solution? A Shifting Paradigm

Prior authorizations are the least automated function in healthcare with providers relying on manual systems and antiquated processes. However, technology alone cannot meet all of the requirements necessary to handle the entire prior authorization workflow effectively. Even in a perfect digital world, there are outlying requests, complex queries, and emergency needs.

Using Infinx’s augmented intelligence prior authorization service solution is an example of what technology combined with human intellect can accomplish in the healthcare business operations field.

Relying on an automated AI-driven software solution supported by experienced specialists ready to handle emergent or complex prior authorizations, providers can process prior authorization in near real-time, with follow-up monitored 24/7. Patient scheduling can occur almost immediately in most cases with less case abandonment, resulting in a better patient experience.

How augmented intelligence elevates the overall discussion:

  • Accelerate current employee throughput to a higher level

  • Augment decision making in the process

  • Reduce manual processing costs and risks

  • Increase consistency of output

  • Continuous self-learning processes

Insurance Verification Brings Opportunity As Well

The first step in this process, even before prior authorization, is securing accurate and valid insurance and demographic information about the patient. By utilizing an insurance verification and benefits eligibility solution, your practice will be able to track and confirm precise patient coverage details in real-time while avoiding later denials due to ineligibility.

Utilizing a seamless integration or portal, front office and scheduling staff would be able to access an extensive payer clearinghouse of over 800 payers across the country to determine eligibility and benefits in real-time, including:

  • Patient’s eligibility and dates of coverage,

  • Primary or secondary insurance relationship,

  • Co-pay and/or co-insurance due,

  • Annual deductible met and remaining, and

  • Any out-of-pocket maximums.

Using the Infinx Insurance Verification & Benefits solution, emergent or problematic verifications would be handled by specialists in cases such as non-automated payers, etc.

As Does Collecting Patient Portions Due

Once the insurance information is determined, it is critical for overall practice financial health that all estimated patient portions due are collected before the time of service if possible. Today’s consumer is conditioned to pay before receiving goods or services, but it is often the practice or hospital that neglects to ask for payment until the patient arrives or even after insurance has paid.

With automated patient pay estimates, you would have the following:

  • Real-time patient pay estimates

  • The ability to incorporate provider fee schedules to determine accurate patient estimates based on current information

  • Robust cost estimation logic that enables precise and immediate amounts due

With strong, well-defined financial policies in place, expert collections training for staff, and clear-cut automated estimates available, patient portions collected before the time of service no longer have to slowly wind their way to either payment (often several months post-visit) or collections. Additionally, giving patients automated payment options greatly increases payments – patient portals, apps, email notification, etc.

Due to the pandemic, providers are finding themselves with financial and care-related challenges.  By taking advantage of advanced technology coupled with human intelligence, we are entering a new phase of proactive revenue generation and collection less reliant on slow antiquated systems and payer limitations, and more on resilience and purposefulness.

Contact us to learn more about automation for prior authorization and our Prior Authorization Software solution that provides you with complete end-to-end prior authorization coverage.