Prior authorization is meant to make sure treatments are needed and cost-effective. But it adds a lot of extra work. The American Medical Association says about 92% of doctors report delays in care because of prior authorization. Also, 86% say these delays hurt patient outcomes. Providers spend about 24 minutes per prior authorization request when using phone calls, faxes, and emails. Even with health plan portals, it still takes about 16 minutes per request. These delays can upset medical staff and slow down patient treatment.
Prior authorizations can also cause lost money for healthcare providers. This happens because denied requests need to be sent again or appealed. Denied authorizations lower cash flow and raise admin costs. Delays in payment can really hurt smaller practices where money flow is tight. More admin work also leads to staff burnout. This affects the quality and speed of healthcare services.
This shows why it is important to make prior authorization easier. This can be done by having the right people, good workflows, and using technology.
Managing prior authorizations well needs good staffing and workflow design. Experts like Matthew Bridge and Ryan Chapin from AGS Health say healthcare providers do better if they use a mix of in-house, outsourced, or hybrid staffing models to handle workloads.
Besides staffing, having clear and standard workflows is key. Providers should get all documents before starting, make clear communication with payers, and use checklists to avoid mistakes and late submissions. Working together with payers can help create agreements that speed up approval for trusted providers, often called “gold carding.” These methods reduce manual work and increase accuracy.
Using the same prior authorization process across departments helps work go more smoothly. Doing forms by hand, making follow-up calls, and sending faxes waste time and cause errors.
Electronic prior authorization (ePA) systems have helped a lot. For example, Surescripts’ ePA ties prior authorization requests directly into Electronic Health Records (EHRs). Providers can send requests and get approvals right away during patient visits. Studies show ePA:
Healthcare groups say they can do about ten electronic prior authorizations in the time it used to take to do one or two by hand. This helps workers have less work and lets clinical teams start treatment sooner.
New technology like AI and robotic process automation (RPA) is changing how prior authorizations work. These tools cut down on slow manual work, lower mistakes, and give useful information to help manage denied requests and improve operations.
Smart AI systems can do many parts of prior authorization automatically. For example, Zyter|TruCare automates 90% of fax-based requests, cuts processing time by 60%, and reduces data errors by 70%. This lets clinical staff spend more time on patients and less on paperwork.
AI can do things like:
When combined with workflow automation, AI smooths out insurance checks, claims submissions, appeal letters, and prior authorization requests. These are important parts of managing money in healthcare.
RPA uses software “bots” to do tasks that follow fixed rules without needing people. In healthcare, RPA is used for:
RPA helps healthcare groups cut costs, speed up claim decisions, and improve data accuracy. Some providers got their turnaround time down from days or weeks to just hours or minutes.
Easy-to-use RPA platforms let IT teams build automated workflows without needing lots of coding experience. This makes it faster to start using automation in busy medical settings.
Hospitals that use AI and RPA in managing money have reported good results, such as:
By automating routine tasks linked to prior authorization, healthcare providers speed up cash flow, reduce staff burnout, and lower patient wait times.
Following rules is an important part of making prior authorization better. In January 2024, the Centers for Medicare and Medicaid Services (CMS) created a new rule for better electronic data exchange between providers and payers. This uses HL7 Fast Healthcare Interoperability Resources (FHIR) APIs.
The rule says that payers for Medicare Advantage, Medicaid, CHIP, and other health plans must:
This rule could save about $15 billion over ten years by cutting admin work and faster approvals. It also supports automation by allowing some flexibility in meeting standards under HIPAA.
Healthcare groups need to get their IT ready for these rules and use electronic prior authorization systems to stay compliant and improve operations.
Cutting down on prior authorization work needs better teamwork between providers and payers. Platforms like Epic’s Payer Platform have helped by:
Shared workflows let teams check the status of requests in real time and cut back on manual follow-up. Transparency builds trust and stops work from being done twice. Tools that show prescription benefits can help providers by giving coverage details, cost info, and alternatives when prescribing. This lowers unneeded prior authorization requests.
Medical practice leaders and IT managers have a key role in using these strategies to improve prior authorization workflows:
By improving processes and using automation, medical practices can lower the work needed for prior authorizations, do better with money management, and most importantly, help patients get care faster.
Making prior authorization workflows better is possible by using smart staffing, clear processes, good teamwork with payers, and new technology like AI and automation. Practices that use these methods can work more efficiently and reduce the problems caused by too much admin work in healthcare in the United States.
Prior authorization is a process where payers require healthcare providers to obtain approval before delivering certain medical services, procedures, or treatments. This ensures that the services are medically necessary, appropriate, and cost-effective, helping to control healthcare costs and prevent unnecessary treatments.
The complexity has increased due to the shift from fee-for-service to value-based care, stricter documentation requirements, and the expansion of procedures requiring authorization. This has made it harder for staff to manage the process efficiently, increasing administrative burdens and operational challenges.
Prior authorization leads to increased administrative costs, reduced revenue from denials, and delayed payments. Denied authorizations can cause lost income that is difficult to recover, while delays affect cash flow, negatively impacting both large and small healthcare practices financially.
It drains resources by consuming time on administrative tasks, increases workload without additional staffing, and leads to errors and delays. These operational issues cause burnout among revenue cycle management staff and adversely impact patient care and satisfaction.
Patients experience delays in receiving necessary care, financial burdens from denied coverage, and confusion over billing issues. These factors contribute to negative patient experiences, potentially worsening health outcomes and causing stress and dissatisfaction.
Healthcare providers should develop workflows that improve efficiency and ensure proper staffing, either with in-house teams, outsourced services (often offshore) for cost savings, or a hybrid model combining both. Proper resource allocation helps manage the prior authorization workload effectively.
Best practices include careful vendor selection with focus on ROI, establishing SLAs, ensuring HIPAA compliance, investing in knowledge sharing and transformation, promoting collaboration, using analytics to monitor performance, and implementing governance models to align expectations and prevent service issues.
Standardizing workflows across different authorization types reduces manual steps, minimizes errors, and improves communication with payers. Capturing necessary information upfront and tracking authorization status ensures timely approvals and reduces payment delays.
Technology automates routine tasks using AI, bots, and intelligent automation tools, reducing staff workload and errors. Predictive analytics help identify denial patterns, enabling process improvements. Partnering with technology vendors can facilitate automation in organizations lacking internal capabilities.
Enhancing prior authorization efficiency reduces administrative burdens and staff burnout, improves cash flow by minimizing payment delays and denials, ensures timely patient care, and leads to better patient satisfaction and operational performance overall.
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