As industry leaders continue to call for reform and revision to the process of prior authorizations (PAs), only limited change has occurred. Most commercial insurance payers are increasing the list of testing, procedures, and medications that need PAs.
Just recently, the Centers for Medicare and Medicaid Services’ (CMS) administrator, Seema Verma pinpointed PA 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 requires PAs are serious; no one refers a patient for an MRI unless they have serious concerns. Most PAs 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 PAs.
6 Benefits Brought by Digital Prior Authorizations
When looking for a solution to the dizzying effects of growing and expanding PAs, it’s important to remember that the vast majority of practices industry-wide use manual systems to manage their PA inventory. Only 13% of practices (2019 CAQH Index on Conducting Electronic Business Transactions) use advanced automation to process their PAs when doing so would lead to the following benefits:
- PA’s Processed in Real-Time — By utilizing an automation and AI-driven solution, non-emergent PAs can be processed, submitted, and followed up in record time with outliers and emergent PAs handled by experienced specialists. Using an Authorization Determination Engine, you can determine if a PA is required, or not, in real-time.
- Lower Denial Rates — By ensuring that all PA 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 PA notification, completed PAs would be routed immediately to the scheduling group so that patients can be scheduled efficiently with minimal need for rescheduling.
- Reduced Patient Abandonment of Treatment — According to the 2019 AMA Prior Authorization Physician Survey, 74% of providers reported that the prolonged PA process leads 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, PAs 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 solutions that will exceed your radiology practice’s needs.