Do Prior Authorizations Make Sense with Value-Based Initiatives? Insurance Payers Say YES!

With most hospitals and providers squarely aligned in the “no more prior authorizations” camp, insurance companies face strong headwinds. The American Medical Association (AMA) (joined by numerous other healthcare organizations) penned and submitted a consensus statement to insurance payers requesting reform that would streamline the process and make it less burdensome to providers. To date, it’s fallen on deaf ears.

According to the organization, America’s Health Insurance Plans (AHIP), their recent survey shows that insurance payers believe that 91% of large plans surveyed (>50K covered lives) feel that prior authorizations (PAs) have had a significantly positive impact on the quality of care. An equal number (91%) stated that PAs increased affordability, further bolstering their argument that PAs are a positive necessity.

How Do Prior Authorizations Support Value-Based Initiatives?

Enter value-based care, and the call for reform from hospitals and providers escalates. However, insurance payers are firm in their belief that PAs reinforce value-based contracting and align with their goals to use evidence-based provider input to develop those contracts.

According to AHIP, “Prior authorization is often part of a broader medical management strategy that includes offering providers evidence-based resources, comparisons to their peers, and incentives to provide value-based care,” with 49% advocating an increase in the future. Seen as a supplement to evidence-based care goals and not a redundancy, PAs are valued for the insights they provide on costs, safety, and use (or misuse) of resources.

If Prior Authorizations Aren’t Likely to Stop, Then Change the Conversation

If we look at why providers so adamantly dislike PAs, we find these major issues:

  • Extremely burdensome and frustrating for providers and administrative staff to process, follow, and appeal
  • Postpones needed patient care and creates scheduling inefficiencies that may lose the patient altogether
  • Tremendously costly in staff time and resources with hours spent on hold and reworking approvals

Could part of the problem be that 87% of providers use a manual system that adds hours instead of redeploying those efforts to improve the patient experience?

Consider Advanced Automation to Shift the Focus

With today’s cloud-based technologies and tech-enabled automation systems, PAs no longer have to require the hours, the frustrations, or the patient scheduling problems that have plagued them for years. When using AI-driven automation technology, healthcare providers can experience PAs from a whole new real-time perspective, including:

  • Determining necessity based on patient’s referring diagnosis and insurance requirements and guidelines,
  • Collecting necessary information on patient demographics, verifying insurance benefits, and confirming allowable care,
  • Submitting completed PA to the appropriate insurance payer for review,
  • Following up by monitoring payer portals 24/7 and retrieving case status updates,
  • Generating and resubmitting appeals if necessary,
  • Providing full transparency into PA workflow using analytics and status reporting to track every claim,
  • Supporting emergent or complex PAs through a team of highly-training, integrated specialists available to complete and finalize outlier situations.

With a more efficient process accomplished in real-time, patients can be scheduled quickly, and clinical and administrative staff members can focus on higher-level functions like an improved patient experience.

While the debate continues over reforming the PA process in the age of value-based care, it seems unlikely that it will go away entirely, and digital enhancement may be the most effective solution.

As demonstrated success with over 2M PAs processed annually, the Infinx Prior Authorization Software has a d 98+% accuracy rate coupled with a <2% claims denial rate with their electronic prior authorization solution. Additionally, they have been able to secure 30% increases in client productivity through automated processing. Consider the impact on your bottom-line with results like that.

Contact us to discuss our prior authorization solution that makes sense with value-based initiatives.

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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