What service or amenity could your healthcare organization provide or deliver if you were freed up from the prior authorization (PA) process? According to a recent MGMA survey, 90% of providers acknowledge PAs account for patients receiving delayed care with up to 30% abandoning care or medications altogether.
What started as a utilization management technique meant to ensure the quality of care has turned into an administrative nightmare that never seems to find a resolution. Administered and mandated by insurance providers, the burden has fallen to providers and hospital systems to justify their care decisions for procedures, tests, and many pharmaceuticals.
Organizational Benefits of a Third-Party Partner
PA lends itself particularly well to utilizing a third-party partner that brings state-of-the-art automation, artificial intelligence (AI), and machine learning to tackle the multi-layer process. While your organization would still provide strategic leadership and overall financial responsibility, a third-party partner takes the reins on the day-to-day PA workflow in the following ways:
- Determines if a PA is required, or not, using AI-driven software that can also initiate the claim immediately.
- Capture and increase revenue with timely submission and execution
- Accelerate PA approval, enhanced by a vast database of insurance payer information
- Increase scheduling efficiencies through automated, real-time follow-up and status notification
- Provider integration through API or HL7 bi-directional integration with local EHR/EMR
- Emergent requests and outliers handled by certified, highly trained specialists
- Superior analytics and reporting to enhance your strategic and financial management process
What Can Your Organization Expect to Gain?
Taking on a new partner can be unnerving in any setting; when it comes to impacting your bottom-line revenue, you must weigh the possibilities. Look at some of the positives to be gained by increasing your revenue team:
—With an automated PA process that fully leverages machine learning and AI-enhanced workflow, PAs can be submitted, monitored, followed up, and results communicated in real-time with little human interaction required.
—Costs are reduced as staff and resources are redeployed or reduced since they are no longer needed to manage a manual, redundant PA process.
Focus on Patient Care
— Your in-house team can turn their focus to the patient care experience with enhanced scheduling, more focused provider time, and more efficient billing.
—The reimbursement process in healthcare brings with it a certain amount of risk. Insurance markets, government regulations, financial conditions, and technologies all change very quickly. Third-party partners assume and manage this risk for you by staying up to date with the latest information.
Whether a hospital-based organization or a specific specialty provider, i.e., cardiology, orthopedics, pathology/laboratory, radiology, etc., you can greatly benefit from a third-party partner utilizing state-of-the-art technology and certified specialists to enhance your PA system. With further modular expansion, you could also see the benefits of insurance verification or Clinical Decision Support Mechanism (CDSM) enhancement that would create even more benefits to your bottom line revenue and your patient.
Schedule a demo today to see how the right RCM partner can benefit your healthcare organization today.