Prior authorization is used as a tool to ensure high quality of care while controlling healthcare spending. The process itself, however, is extremely labor-intensive and has become a significant source of administrative burden for providers and health plans alike.
In fact, administrative prior authorization processes have been estimated to contribute as much as $25 billion annually to the cost of healthcare in the United States according to CAQH. And as prior authorization’s complexities continue to increase, struggling to track all those requirements in binders and spreadsheets just isn’t going to cut it anymore.
Do More With Your Resources.
Time is of the essence. Resources are scarce. Denials are looming. It’s vital to make sure your organization is doing the absolute most with your resources.
Prior authorization automation can make a significant difference in your workflow, ultimately preventing errors and easing the burden of processing denials.
For instance, an end-to-end authorization software suite can pull necessary clinical data directly from your organization’s EHR, create a medical review within your case management system, and send notification of the patient’s appropriate care determination back to the EHR. It also determines if an authorization is required and whether medical necessity is needed. This expedites the medical review process and frees staff to focus on patient care and high-risk, complex accounts. Hello, efficiency!
But not all prior authorization automation vendors are created equal. Here’s an overview of content your ideal vendor should have.
3 Content Areas to Automate in the Prior Authorization Process
1. Medical Necessity. Your software must determine whether an authorization is required right away. That means rules must be in place, and the more of them, the merrier.
Your vendor should cover as many commercial payers as possible and be able to upload their content to your EHR in order to discover NCD/LCD medical necessity requirements. Using rules to validate whether you should use standard electronic transactions or data from payer websites to facilitate the cost-effective exchange of information between healthcare providers and payers is crucial.
2. Initiation. On average, a manual authorization request can take as much as 20-30 minutes to prepare per patient.
Finding a software solution that can automatically initiate and obtain authorizations for scheduled services, submit the inquiry, and confirm whether a prior authorization is approved or denied without human intervention must be a part of your authorization automation strategy.
3. Notification. Healthcare organizations are required to notify insurance payers in a timely manner when a new patient is admitted. And the sooner, the better. Unfortunately without automation, the probability of missing the one to two day window of notification for certain payers to create and manage an authorization record skyrockets.
But there’s no reason to miss that window. Automating the notification of admission eliminates the potential to miss while also giving you access to payers that may only take notifications via a web portal.
A Quick Recap
Requesting a single authorization takes at least 15-20 minutes per auth when done manually, requiring a staff member to visit a payer’s website, then copy and paste a significant amount of non-clinical and clinical patient data into various fields. For a large multi-facility IDN with high patient volumes, even if only 10% of accounts require an authorization, the process can require delegating hundreds of employees or writing significant outsourcing checks. But all that manual labor is now a thing of the past.
Your authorization solution can (and should) offer you the ability to automate the menial tasks of logging into payer websites and phone calls. And it should be constantly checking and rechecking those ever-changing prior authorization rules and requirements.
Prior authorization automation allows you to increase the amount of authorizations completed per hour, with far fewer staff. It can also help you focus your staff on high-value, complex accounts and engagement with patients, making your 100 employees feel like 1000.