Prior Authorization Burden

Providers reported that 88% classify the burden of prior authorizations as extremely high.

Prior Authorizations are designed to ensure that member care meets appropriate care standards, reimbursement requirement and policies set forth by the health plan.

From MGMA (Medical Group Management Association) most recent MGMA STAT[1] poll, it became known that 81% of Medical Groups said that payer prior authorization requirement increased since 2020. Many of the healthcare providers have added full time position(s) to handle prior auth work process.

Streamlining the prior authorization process can lessen that burden of obtaining prior authorization. This also gives confidence to the provider and patients confidence that the prescribed care meets the health plan requirements for reimbursement, and patients will not be left with a surprise bill.

According to AMA report[2] the entire authorization process affects patient care negatively; 94% of the doctors reporting care delays while waiting for health insurers to authorize necessary care, and 79% saying patients abandon treatment due to authorization struggles with health insurers.

Prior authorization approval turnaround time results in delayed care. Too often, multiple phone calls, emails, and other contact between the provider and payer are required to collect and verify all of the information needed to process a prior authorization request. This means it can be days or even weeks before patients get the care they need, potentially resulting in missed treatments, and certainly causing greater stress for patients and scheduling hassles for providers. Consider leveraging electronic solutions that can automate the process where possible, reducing the effort and improving data quality for submissions and status determinations. Also, look for solutions that support online collaboration throughout the process, reducing the time spent on the phone and exchanging faxes, and that provide a robust audit trail of all interactions.

Lack of transparency about the status of an authorization?can cause delays and costly back and forth between providers and payers. Payers can offer an online status lookup containing clear instructions when additional information is needed, reducing the burden on payer call centers and making provider processes more efficient. Consider proactively sending status updates and follow-up communications to providers electronically through the same portal where the authorization was submitted, so providers are kept up to date efficiently and effectively.

Transmitting supporting documentation?is too often done manually via fax or mail, which can take a long time, are difficult to keep track of for providers, and hard for providers to correlate to the correct authorization request. Consider implementing a secure online solution that allows providers to easily send information electronically when submitting the authorization or when more information is requested in follow up. Clear and codified rules defining the types of documentation required can even allow such systems to automatically collect the necessary content from a provider’s EMR, saving significant provider effort.

How AI (Artificial Intelligence) is going to revolutionize process of obtaining Prior Authorization:

Streamlined prior authorizations are rising from the ashes after MultiCare Connected Care and Regence tap HL7 FHIR (Fast Healthcare Interoperability Resources) to make the process interoperable and in real-time.

Applying an interoperable data standard to the prior authorization has cut down the work MCC and Regence due to complete the process. Using FHIR, for example, MCC’s prior authorization team can now click a button within the EHR (Electronic Health Record) system to start a request for service pre-approval and have the necessary data populate.

Electronic prior automation adoption has been steadily increasing, according to the latest CAQH (Council for Affordable Quality Healthcare) Index, but the process is still one of the most manual compared to other medical administrative processes. Many providers still use the phone, mail, or fax to submit requests to payers. However, partial electronic adoption is also to blame. Payers typically use their own electronic solutions and portals to manage prior authorizations, leading to the complexity MCC experiences every day with prior authorizations.

Total RCM Solutions have evolved with smoother process to overcome the problems faced while obtaining Prior Authorization from the payers. We have a dedicated experts who with the help of technology will be able to customize the process depending upon the procedure and payers eventually making sure to obtain authorization appropriately.

[1] https://www.mgma.com/data/data-stories/prior-authorization-burdens-for-healthcare-provide

[2] https://www.ama-assn.org/practice-management/prior-authorization/covid-19-peaked-prior-authorization-s-harmful-burdens