“Streamline your workflow” and “increase efficiency” have quickly become some of the most common admonitions in healthcare. But with the constant bombardment of government interference, EHR modernization, increasingly complex requirements from insurance companies, staffing constraints and growing patient volumes, attempts to do so are falling flat.
Ah, yes… prior authorization: a process seemingly designed for inefficiency.
It’s time-consuming (at the very least) in its antiquated methods of using the fax or the phone, and maddening at its worst, disconnecting staff from their patients and impeding the delivery of care.
In fact, the AMA recently released a survey pointing out that a single patient access employee completes an average of 37 prior auth requests per workweek, with over 853 hours consumed by tasks related to prior auth on an annual basis. That’s 41% of each employee’s working hours.
And it’s costly. We’re talking in the range of $35-$100 per occurrence, according to industry estimates. As such, being able to manage prior authorizations efficiently is critical to maintaining a healthy revenue cycle and avoiding issues, like denied claims, administrative waste, and patient dissatisfaction.
But let’s be clear. It isn’t the concept of requiring prior auth that makes our skin crawl. The need is relevant and understood. Instead, it’s the arduous manual processes that must be undertaken in order to request and receive them.
Healthcare providers can gain tremendously from automating prior authorization verification, submission and notification. Through establishing a more consistent and automated approach, a more efficient prior authorization process emerges.
Yet, even automation can contribute to the challenge, since there are now more RCM vendors to choose from, and not all vendors are created equal.
9 key points to consider when choosing your prior authorization software:
- Steps. Many vendor solutions only automate certain steps of the prior authorization process. Make sure you read the fine print. Some will only automate determination. Others may only do status. You must ask the right questions and narrow down your choices to the best, most comprehensive option for your organization.
- Data. Automated solutions are primarily rules-based, and payer rules are known to change with the blink of an eye. The only way to address the authorization problem is to fully understand the rules and policies of the payer, know where to go to secure the authorization request and how to connect with the payers, and assess the quality of the response. Your RCM solution should have the ability to obtain proof that an authorization check is not required. It should also include an integrated medical necessity check, even after a prior auth has been obtained
- Payers. You need to understand how frequently the data regarding payer rules is updated, how many CPT codes are maintained, the modalities supported, the rules validations conducted, etc. In fact, the more knowledge you have about the ins-and-outs of the payer/vendor relationship, the better. How does the vendor stay up-to-date with payers? Do they have rules maintenance? Follow-up confirmations? Where is the information gathered from? Payer’s websites? EDI? Both? Find out.
- Exchanges. Automated prior authorizations are typically processed using EDI 278 transactions, an Application Program Interface (API), or an HL7 feed. Like all things, each has its advantages and disadvantages, but not all vendors do them all (or any for that matter). You’ll want to look into what your vendor uses, as well as ensure that all the payers you work with can accept the data exchange method you plan to use.
- Changes. If an order changes after a prior auth has been received, how does the technology handle it? A good system will flag the discrepancy or alert staff with next best actions in order to streamline the resubmission process and avoid a denial later.
- Integration. Ideally, your solution will integrate with your EHR, practice management, or RIS rather than requiring a separate interface, but you can’t just assume. Ask. Many vendors are bolt-on technologies, which, in turn, would require your staff to use multiple software platforms when processing prior auth. Talk about even more complications.
- Customization. That point really speaks for itself, but it’s not to be overlooked. You need to make sure the solution you choose is customizable to fit the needs of your specific organization. Blanket AI is not a solution. It only adds to the problem. You need purpose-built applications of machine intelligence tailored to your organization’s problems and goals.
- Support. Prior auths are complex transactions that incorporate a significant amount of data and steps. Even with automation, problems are bound to happen. That’s the nature of the beast. When it does, you want to be sure you have real, human support from an expert who can evaluate the issue and guide you to a solution.
- Results. Many technologies work in theory, but getting prior auth right is too important to leave to promises and chance. Check out other organizations that are using your vendor’s technology. Does the experience match the hype?
With healthcare organizations running on thin margins and payers creating more granular authorization rules at the plan level, reducing errors and increasing efficiency in your prior authorization process is essential to your healthcare organization’s survival and success. As such, keeping these 9 key points in mind while choosing a vendor is key.