As industry leaders continue to call for reform and revision to the process of prior authorizations, only limited change has occurred. Most commercial insurance payers are, in fact, increasing, not decreasing, the list of testing, procedures, and medications that need prior authorizations.
Just recently, the Centers for Medicare and Medicaid Services’ (CMS) administrator, Seema Verma pinpointed prior authorization improvements as a “priority” in 2020 and acknowledged that rules requiring providers to get pre-approval for an imaging exam or surgical procedure, often leads to unnecessarily burdensome paperwork, delays in patient care, and provider burnout.
During a recent speech at the American Medical Association’s National Advocacy Conference on February 11, 2020, Verma labeled this “long-standing problem” in healthcare as “indefensible” as it currently stands.
She further added, “Patients are frustrated, and doctors are sick of pointlessly wrangling with insurance companies…Prior authorization requirements are a primary driver of physician burnout, and even more importantly, patients are experiencing needless delays in care that are negatively impacting the quality of care they receive.”
So What Can Be Done in Radiology?
To combat delaying patient care, it’s important to remember that the radiology procedures/testing that require prior authorizations are serious; no one refers a patient for an MRI unless they have serious concerns. Most prior authorizations required in radiology are for these procedures:
- CT scans**
- PET scans
- Nuclear medicine studies
**Authorization is not required for procedures performed in an emergency room, observation unit, urgent care center, or inpatient stay.
So while there may be reforms in the offing over the next several years, high priced advanced testing procedures like these are most likely going to require a prior authorization.
6 Benefits Brought by Digital Prior Authorizations
When looking for a solution to the dizzying effects of growing and expanding prior authorizations, it’s important to remember that the vast majority of practices industry-wide use manual systems to manage their prior authorization inventory. Only 13% of practices (2019 CAQH Index on Conducting Electronic Business Transactions) use advanced automation to process their prior authorizations when doing so would lead to the following benefits:
Prior Authorizations Processed in Real-Time — By utilizing an automation and AI-driven solution, non-emergent prior authorizations can be processed, submitted, and followed up in record time with outliers and emergent preauths handled by experienced specialists. Using an Authorization Determination Agent, you can determine if a prior authorization is required, or not, in real-time, for diagnostic imaging procedures.
An AI-led Authorization Determination Agent, a proprietary automated solution from Infinx, works in tandem with the state-of-the-art Infinx Prior Authorization Software. The Agent, using augmented intelligence, kicks off the automated preauthorization process by identifying and determining when prior authorizations are needed through a secure integration with a practice’s EHR/EMR or RIS.
The Authorization Determination Agent’s functionality can reduce the time spent on prior authorizations and optimize patient scheduling for diagnostic imaging procedures. Infinx’s Authorization Determination Agent utilizes a combination of artificial intelligence and automation to determine an authorization requirement in minutes, if not seconds, and with a high level of precision.
Lower Denial Rates — By ensuring that all prior authorization requirements are met in a timely manner, denial rates are reduced, which saves time and effort for the business team charged with reworking claim denials and rejections.
Improved Scheduling for Patients — With real-time notification from the Authorization Determination Agent, completed prior authorizations would be routed immediately to the scheduling group so that patients could be scheduled at the time of service.
Reduced Patient Abandonment of Treatment — According to the 2019 AMA Prior Authorization Physician Survey, 74% of providers reported that the prolonged prior authorization process has led to treatment abandonment; patients simply gave up and walked away. With a streamlined and efficient system, patients would be scheduled as soon as possible, and abandonment issues would be alleviated.
Increased Reimbursement — With the current manual system, prior authorizations are a significant cause of unrecognized revenue. By automating the process, much of the problem would be eliminated, not to mention the increase in patient visits when care is no longer abandoned.
Lower Staffing Costs — Instead of spending time on hold and faxing forms, staff can participate in higher-level functions, such as improving the patient’s experience.
When assessing future radiology practice needs, incorporating electronic prior authorizations should be near the top of the list. The gains in efficiency, increase to revenue, and improvements to the patient’s encounter make this solution well worth the effort.
Contact Infinx to learn more about our electronic Prior Authorization Software solution and the Authorization Determination Agent that will exceed your radiology practice’s needs.