Is Automating Prior Authorization On The List Of Corporate Priorities?

Streamlining The Task Of Prior Authorization Requires Standardization Of The Process By Insurance Companies

Illumination initially published this article on Medium!

You may be familiar with prior authorization (PA) if you are a medical professional or a patient. Correspondingly, you must also understand the kind of nuisance physicians and patients sometimes must endure before they can initiate a clinic visit encounter.

Prior authorization is a process health insurance industries employ to verify and approve the necessity of medication, procedure, or treatment about to be offered to a patient by the treating medical professional. In short, prior authorization serves as gatekeeping for the insurance company to control costs for their benefit.

The history of prior authorizations dates back to the utilization reviews in the 1960s and the commencement of Medicare and Medicaid legislation. At the time, "the prior authorization" function was limited solely to the patient hospital admission verification and the need for hospital treatment based on confirmation of diagnosis by two doctors.

While the original prior authorizations rationalized hospital admission audits, today, its scope has broadened and become even more complex.

Amid Increasing Prior Authorization Rate And Complexity, Physicians Are On The Verge Of Burnout

Since its conception, the prior authorization burden has been increasing yearly. Based on March 29, 2016, stat Poll conducted by the Medical Group Management Association (MGMA), 82% of healthcare leaders reported an increasing number of prior authorizations from the previous years. That trend continued to increase through 2022, further exacerbated by the COVID-19 pandemic.

The March 2022 MGMA Stat poll reports that 79% of physician participants experienced an additional increase in the PA rate in the medical practice.

Today the prior authorization paperwork has grown out of control of the physician practices. That is because the task is highly time-consuming for physicians, thus delaying patient access to necessary care.

Handling prior authorization is a chore that takes away valuable time from physicians and is costly for medical practices. It requires additional personnel if the facility intends to streamline the process. A 2009 study estimated time spent for prior authorization requests being over 20 hours a week per medical practice. That translates into one hour of the doctor's time, six hours spent by the clerk, and 13 hours of nurses' time.

The prior authorization process is becoming more and more problematic . For instance, according to reports, insurance companies require more prior medication authorization. That is further intricated by the increasing number of various insurance plans and shifting policies, further complicating already increasing medical practice administrative mandates.

Prior authorization is labor-intensive . The value-based physician reimbursement policies, along with their widely require cost-containment measures. Furthermore, denied claims will require manual handling, which is also costly.

Patients are the biggest scapegoats of prior authorization policies. It creates unnecessary interruptions in their medical care both from a timeliness, quality, and continuity perspective.

Prior authorization management is often intricate, as every insurance company has a different process for submitting PA requests. Such a lack of standardization and predictability often makes us wonder if insurance companies are for facilitating the PA process. However, if so, why should they?

Indeed, prior authorization ensures the financial triumph of the insurance industry . In contrast, the failure to obtain proper approvals means a loss of income for independent physicians. That also means prior authorization turndowns result in declines in provider and patient satisfaction relationships and uncertainties in patient care.

Prior authorization shifts burden of costs from payers to providers, while undermining physician professional credibility.

Why Is It So Complicated To Streamline Prior Authorization Process Thru Automation?

There is a short and long answer to the question of "why streamlining the prior authorization is so complicated!"

The short answer is that it is not in the insurance industry's interest to automate or streamline the prior authorization process.

The long answer is too long to fit within the scope of this piece. However, to cover some core elements, one must mention the reality of continual policy changes and error-prone protocols associated with every insurance claim.

Indeed, there has been legislation in the pipeline since 2018 which demands Congress to place limits only on "Medicare Advantage (MA) plan prior authorization" prerequisites. Yet, we are still hoping to see it passed into law. That is even though some efforts by the Trump administration to deal with indiscriminate prior authorization failed in 2020.

The complexities associated with prior authorization are so that it also hinders the development of an automation protocol.

Insurance industry leaders are no spring chickens!

Insurance companies already understand that to automate the task; we must first find standards and establish the repetitive tasks within those standard protocols and procedures. They have established a process relying on an out-of-date system of fax machines and stopgap manual activities. That is their secret to success as of now!

There are many steps involved in the "prior authorization" process. The payer and provider staff with diverse motivations, workflows, and infrastructure are potential barriers to streamlining prior authorization automation.

Relying on an antiquated system of fax machines and stopgap manual activities will never suffice. Introducing more industry standards may help, but getting ahead of prior authorization and efficiently managing the process requires automation.

But automating the prior authorization process is complicated.

There are a lot of non-standardized steps with many variables involved in every prior authorization case. Every step mentioned introduces their particular motivation for potential delays and errors.

Personnel from both the payer and provider sides participate, each with different motivations, workflows, and infrastructure. Now and again, automating the prior authorization seems unlikely to be in the best interest of the insurance industry!