Addressing the Hospital Prior Authorization Burden

With the insurance industry unrelenting on reducing or streamlining the prior authorization process, hospitals and healthcare systems continue to struggle with the operational implications of a burdensome and redundant system. It’s time to consider an advanced automation solution that offers real-time processing integrated with the EHR/EMR and billing system. Using artificial intelligence and machine learning capabilities, digital prior authorizations improve patients’ access to care, and relieve clinician frustrations.

It doesn’t matter if your providers have recently completed their training or have been board-certified providers for many years; prior authorizations are a necessary step that simply can’t be avoided. While the symptoms requiring therapeutic intervention are undeniable, insurance companies will require providers to document the necessity of treatment before agreeing to reimburse.

Prior authorizations create frustration in a variety of ways, including:
• Delaying patient care for up to three or more weeks
• Causing a provider to alter their treatment plan for expediency
• Being more susceptible to review and rejection because of insurance company bias
• Being administratively burdensome, taking several hours to several weeks to complete
• Negatively impacting the scheduling process and, ultimately, the patient experience

The American Hospital Association (AHA) recently called on the Centers for Medicare and Medicaid Services (CMS) to improve prior authorizations, stating that they strongly recommended changes that would reduce administrative burdens placed on their membership in their efforts to increase advocacy efforts.

Additionally, the AHA signed onto the American Medical Association (AMA) letter^{1Letter to the Honorable Seema Verma, Administrator, Centers for Medicare & Medicaid Services, US Department of Health and Human Services. September 20, 2019.
https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2019/10/AMA-Prior-Authorization.pdf. Accessed on July 29, 2020.} expressing strong concerns to the House of Representatives Committee reviewing H.R. 3107, the Improving Seniors’ Timely Access to Care Act^{2DelBene, S. H.R. 3107 – Improving Seniors’ Timely Access to Care Act of 2019, 116th Congress (2019-2020). House – Ways and Means; Energy and Commerce Committees, Congress.gov. Introduced in the House on June 5, 2019.
https://www.congress.gov/bill/116th-congress/house-bill/3107. Accessed on July 3, 2020.}, meant to streamline and standardize the prior authorization process through Medicare.

While the American Healthcare Insurance Plans (AHIP) group has signed on to support all of the initiatives, insurance payers have been clear that prior authorizations are seen as an effective tool that helps contain costs, and manage the care being delivered and the industry has seen the use of prior authorizations increase, not decrease. 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^{3Ernst, C., JD. Prior authorization pains growing for 9/10 physician practices. Medical Group Management Association, MGMA Stat, Federal Compliance. September 19, 2019.
https://www.mgma.com/data/data-stories/prior-authorization-pains-growing-for-9-10-physici. Accessed on July 12, 2020.}.

While there has been growing discord about prior authorizations for several years with major governmental and industry representative bodies joining the chorus, little has changed. Even if foundational improvements are considered, the prior authorization process will likely continue in a new form, but still, require clinician and administrative time to manage. Being proactive in facilitating an efficient process seems to be the best solution.

Regardless of the industry stakeholder intention, it doesn ’t appear that prior authorizations will go away completely. Rather it’s more likely that insurance companies will reign supreme, and they will continue in some (hopefully) streamlined form.

No matter how frustrating, prior authorizations do seem to help curb healthcare costs. So the question may be how to make them effective in a hospital or healthcare system setting while reducing the administrative burden/costs and improving revenue? Here are three ways to make the process more functional:

1. Always submit organized, clear documentation

2. Be prepared for clinical review

3. Consider a fully-automated prior authorization process

Using up-to-the-minute advanced automation, Prior Authorization Software, that uses ar tificial intelligence and machine learning capabilities, is the most beneficial solution.

To outline, cloud-based, AI-driven software can be integrated bi-directionally with the hospital’s EHR/EMR and billing system. As soon as the patient’s order is input, evaluations, and treatment requiring prior authorizations would be electronically identified, provider/facility detail, patient demographics, and test/diagnosis information would be collected, and an approval request submitted to the insurance payer portal required.

AI-driven software with machine learning capabilities would acce ss 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 t o several days or weeks can now be accomplished in seconds with a 98+% accuracy rate, as documented by an Infinx case study.

Let’s take a focused look at the impact aut omated prior authorizations can have in hospitals:

According to the 2019 CAQH Index, each individual prior authorization industry-wide costs, on average, $14.24 to facilitate manually, while using an electronically automated system would cost $1.93 per PA^{6Ibid. v.}. This is a savings of $12.31 per prior authorization and untold hours of frustration and rework.

The trickle-down effect would be a reduction in denied or reject claims that are currently left unresolved or abandoned with overwhelmed business staff lacking the time or understanding to pursue.

Using the Infinx Prior Authorization Software platform, a seamless and scalable solution is created that uses Health Level 7 (HL7) or Application Program Interface (API) based integration and is compatible with all leading EHR/EMR, and hospital billing systems. The Infinx Prior Authorization Software solution embeds all Patient Health Information (PHI) in layers of security that is Electronic Data Interchange (EDI) compliant and stores the data on the cloud using 64-bit and 256-bit encryption that guarantees 100% HIPAA compliance^{7,Napco’s iBridge Technology Named Top Innovation of 2014 by Security Sales & Integration Magazine – Recurring Revenue Model Makes iBridge a Top Choice for Security Dealers. January 13, 2015.
http://investor.napcosecurity.com/2015-01-13-NAPCOs-iBridge-Technology-Named-Top-Innovation-of-2014-by-Security-Sales-Integration-Magazine. Accessed on February 3, 2020.8Integrating Prior Authorization Solution with Epic PMS While Protecting PHI at a Pennsylvania Hospital Group. Infinx Case Study. 2018. https://www.infinx.com/resource-casestudy/integrating-preauthorization-solution-with-epic-pms-lt/. Accessed on February 2, 2020.}.

As prior authorizations continue to grow, differentiating your hospital or healthcare system 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.