Assuaging the Prior Authorization Headache  

By Matt Bridge and Ryan Chapin of AGS Well being 

The prior authorization course of has advanced in complexity because the healthcare business transitions from fee-for-service to value-based care. On the identical time, payers are increasing the variety of companies topic to prior authorization to ascertain medical necessity and appropriateness. It’s a one-two punch that leaves suppliers and supplier organizations struggling underneath the burden of a previous authorization burden that, left unaddressed, can have long-term income cycle impacts.  

Immediately’s prior authorization course of includes time-consuming steps, together with gathering and submitting medical paperwork to insurance coverage firms and ready for approval. It additionally typically includes coping with denials and appeals – all whereas steering round required documentation turns into stricter.  

The variety of procedures topic to authorization can be increasing, creating new challenges for workers who should perceive the scientific documentation and workplace notes essential to assist the authorization. This additionally means the addition of recent administrative necessities with far-reaching impacts on funds, operations, and sufferers. Moreover, when establishing a centralized prior authorization workforce is infeasible, expanded prior authorization wants exacerbate the issue of competing priorities for workers tasked with acquiring authorizations amidst different core obligations, together with affected person care. 

Prior Authorization Challenges  

The influence of at this time’s difficult prior authorization setting is felt in three key areas:  monetary, operational, and the affected person expertise. 

On the monetary entrance, the executive burden of prior authorization has elevated steadily through the years, resulting in extra prices and workload. Among the many most vital monetary impacts are larger administrative prices and diminished or misplaced revenues because of denials, which could be tough to overturn. The prior authorization course of may also delay money move. 

Operationally, the elevated effort and time required to handle prior authorization is a useful resource drain that pulls employees away from different vital duties, together with patient-facing actions. It additionally will increase the workload of income cycle administration (RCM) employees, resulting in burnout and employees turnover. For instance, absent a devoted prior authorization workforce, entrance desk employees are sometimes charged with acquiring prior authorizations along with their affected person obligations.  

The complexity of the prior authorization course of may also negatively influence affected person satisfaction and high quality of care. Not solely is it complicated and irritating for sufferers, however it may well create delays in care that may result in avoidable well being outcomes. It will probably additionally create an sudden monetary burden when a previous authorization request is denied – a burden that may generally outcome within the affected person refusing wanted care. 

Ache Aid Methods 

Assuaging the headache created by these damaging impacts requires a “individuals, course of, expertise” strategy that mixes workflow optimization, streamlined processes, and superior expertise instruments that work collectively to scale back the burden of prior authorizations. 

Some of the crucial steps for navigating the prior authorization course of is optimizing and growing workflows that profit suppliers’ backside line. This contains making certain the best assets are in place to create a high-performing prior authorization workforce able to effectively managing the prior authorization course of.  

Centralized groups are usually best and could be profitable by way of any of the next fashions: 

• In-house (least cost-effective): Sourcing in-person or digital assist from the U.S.  
• Outsourced (most cost-effective): Sourcing digital assets from international locations outdoors the U.S. 
• Hybrid (cost-effective): Using a mix of onshore and offshore assets. 

One other key technique is to standardize processes for prior authorization workflows to make sure correct and constant outcomes. Suppliers must also work carefully with payers to grasp the prior authorization necessities for every and monitor the standing of requests to make sure that they’re authorized in a well timed method. 

Leveraging expertise can considerably enhance the effectivity and accuracy of the prior authorization course of. Automating sure features of the method utilizing generative synthetic intelligence (AI), superior bots, or clever automation instruments can cut back workloads, permitting employees to concentrate on extra crucial duties whereas minimizing the danger of errors. It will probably additionally cut back guide touches and enhance employees effectivity.  

Lastly, using predictive analytics to determine tendencies and patterns in prior authorization denials and rejections allows vital course of changes.  

 Simplifying the Course of 

The more and more advanced prior authorization setting doesn’t must imply a everlasting migraine for healthcare organizations. With the best methods and instruments in place, suppliers can keep forward of the adjustments and speed up and streamline the prior authorization course of, bettering efficiencies and decreasing employees burden and burnout – all whereas making certain sufferers obtain the care they want in a well timed method.