Has COVID-19 Further Amplified the Truth About Prior Authorization Care Delays?

It’s no secret, the American Medical Association (AMA) notes in their 2019 Prior Authorization Survey that 91% of doctors report that prior authorizations delay care while risking potential treatment abandonment from patients. What we’ve seen during the COVID-19 pandemic is increasing care delays and medication shortages that are impacting patient outcomes and having severe health consequences for certain patients.

As an example, results from a recent American College of Rheumatology survey found that almost half of the patients surveyed (47.9%) needed prior authorization before obtaining a much-needed prescription. With the pandemic in full swing, many of these patients’ most common medications were simply out of stock, including hydroxychloroquine, methotrexate, gabapentin, acetaminophen, and ibuprofen, further delaying vital treatment.

Temporary Solutions Set to Expire Soon

Many insurance payers had relaxed prior authorizations with much prodding from the AMA, to remove delays, including for all diagnostic testing and treatment related to COVID-19, but only through the end of summer. With a shortage of guidance at the federal level, many states have stepped in to impose guidelines creating a confusing patchwork of regulations and time extensions interpreted differently by the various insurance payers.

Putting the onus on providers to navigate the prior authorization minefield, Dr. William Shrank, Humana’s chief medical officer, recently stated, “Humana is committed to supporting clinicians by providing practical solutions to alleviate the administrative burden and boost system viability during these extraordinary times.” But, again, no commitments to specific timeframes and guidelines for relaxed prior authorization requirements.

What is a Proactive Solution Available Today?

So, heading swiftly towards 2021, COVID-19 continues to impact patient reimbursement through burdensome and incoherent prior authorization guidelines made even more complex by a lack of a central theme. Since prior authorization requirements are not going away in the long term, now is a time to consider an electronic, AI-driven prior authorization solution that will automate the process and make sense of the patchwork of insurance payer guidelines and restrictions.

To outline, cloud-based and AI-driven software can be integrated bi-directionally with a hospital or practice’s EHR/EMR system and the billing system being used for client management. As soon as the patient’s order is entered into the EMR/EHR, tests or medications requiring prior authorizations would be electronically identified. Also, provider/facility details, patient demographics, and test/diagnosis information would be collected, and an approval request submitted to the insurance payer portal.

AI-driven technology with machine learning capabilities would access continually updated insurance information clearinghouses storing thousands of insurance groups and plans, each with their unique guidelines and requirements and electronically determine the prior authorization parameters for routing the request. Prior authorization approvals that once took several days or weeks can now be initiated in real-time with a 98+% accuracy rate, as documented in an Infinx case study.

The Bottom Line

While healthcare associations and government entities continue to discuss streamlining and automating prior authorizations during the COVID-19 pandemic and beyond, it seems clear that the process will remain in place as a way for insurance payers to control care. Meeting the challenge seems a more prudent and proactive response instead of waiting for change to occur, and an automated AI-driven prior authorization solution would fit the bill, decreasing administrative workflow and increasing patient and provider satisfaction.

Contact us to learn more about AI-driven electronic prior authorizations and it’s role in minimizing workflow and increasing patient and provider satisfaction.

About the Author

Infinx
Infinx Healthcare provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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