For all but the most routine, prior authorizations are required for most procedures, modalities, medications, and tests throughout the healthcare industry — and physical therapy (PT) and occupational therapy (OT) are no different. Whether because of misunderstanding or cautious administration, insurance payers seem to want prior authorizations before providers can begin treatment.
The time involved in processing prior authorizations siphons valuable resources away from where it’s needed while staff processes redundant paperwork, sits on hold, faxes and or re-faxes paperwork, all in the hopes of obtaining a quick answer. With over 87% of healthcare providers using a manual system, it’s no wonder why the entire process feels punitive and overly burdensome.
According to the Medical Group Management Association (MGMA), 90% of healthcare leaders report that payer prior authorization requirements are increasing with no end in sight to make matters worse.
Improving the Prior Authorizations Process for Physical Therapy and Occupational Therapy
Using advanced automation and artificial intelligence technology, using a prior authorization software may be the solution with the most overall benefits.
To outline, AI-driven software can be integrated bi-directionally with the physical therapy or occupational therapy practices EHR/EMR, and the billing system used for client management.. As soon as the patient’s order is input, tests or medications requiring prior authorizations would be electronically identified, provider/facility detail, patient demographics, and test/diagnosis information would be collected, and an approval request submitted in real-time to the insurance payer portal required.
AI-driven software with machine learning capabilities would access continually updated insurance information clearinghouses storing thousands of insurance groups and plans. Each with their own unique guidelines and requirements and electronically determines the prior authorization parameters for routing the request. Prior authorization approvals that once took between a couple of hours to several days or weeks can now be accomplished in seconds with a 98+% accuracy rate.
Let’s look at the impact automated prior authorizations can have:
Initial Processing — From the moment patient information is entered into the EHR/EMR system; guided processes monitor the key identifiers to initiate prior authorization approval, while constantly updating payer requirements, the system stands ready to gather the required information to initiate the request in real-time.
Business or clinical staff no longer have to manually process forms, wait on hold, or fax repeatedly and can now refocus their time on higher-level functions.
Continual Follow-Up — Once the prior authorization approval has been submitted, electronic follow-up occurs 24/7 until a final resolution is obtained. If additional information is required or an appeal is necessary, the practice is notified immediately so that a response can be crafted and submitted as soon as possible.
Dashboard Notifications — Waiting for insurance payer responses has historically been a time-consuming affair that took hours of follow up and burdensome administrative effort.
With an interactive dashboard, today’s AI-driven software gives a complete snapshot and clarity on all active prior authorization requests so that patient and clinician questions can be answered immediately, and follow-up can occur as necessary.
Scheduling — Alleviating the frustrations of scheduling and rescheduling patients based on prior authorizations, a physical therapy or occupational therapy group or department would have much more accurate parameters allowing a more efficient process for everyone. This would improve the patient’s experience and allow the providers to focus on care.
AR and Claims Management — With fewer prior authorization problems comes less rejected or denied claims, possibly up to 31% fewer according to the MGMA, and more revenue is hitting the bottom line. As a bonus, AI-driven software exists that handles denied claims like prior authorization solutions with a >95% quality standard.
Analytics and Reporting — Bringing full transparency to future operations, timely analytics, and reporting will pinpoint any breakdowns inefficiency or areas needing improvement so that future patients benefit from an even better experience.
As reliance on the field of physical therapy and occupational therapy continues to grow, differentiating your group or department from others by offering pristine business support to referring providers or self-referral patients helps in securing future potential patient growth. Your referring provider base will see the benefit to their patients with more timely care initiation and less cumbersome reimbursement.
While healthcare associations and government entities continue to discuss streamlining prior authorizations, it seems clear that the process itself 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.
Contact Infinx to schedule a demonstration and learn more about the efficiencies gained using an automated prior authorization software solution.