The challenges prior authorization presents to healthcare groups and physicians continue to increase. A 2021 American Medical Association (AMA) survey found that 93% of physicians report that prior authorization results in care delays. One-third said that prior auth delays have caused at least one of their patients to experience a serious problem, such as hospitalization, disability, and even death.
Prior authorization is not going away. Payers are requesting it for an increasing number of medications and procedures. That means it’s more critical than ever for healthcare groups to find ways to minimize their prior authorization burden.
This article looks at crucial steps you can take to achieve this critical objective.
Payer rules are constantly changing. Their sheer volume makes it easy for healthcare groups to miss ones relevant to the care they provide patients. Unfortunately, many groups only learn about PA changes after they begin receiving claim denials due to procedures and medications that previously didn't require prior authorization.
Therefore, it is critical for healthcare groups to have processes in place to ensure they keep up to date on the rule changes insurers make. Healthcare providers must subscribe to newsletters from all their payers and carefully study each document.
Successfully getting timely prior authorizations requires much knowledge that is learned only through experience and repetition. Staff members will begin to learn the nuances of each payer.
Assign staff members particular tasks related to Prior Authorizations.
This policy will give accountability to people in your organization and will work to ensure staff members complete prior authorizations more quickly and with fewer errors.
Every group should have a master list of procedures and medications that require authorization. Staff must continually update this document.
The team members assigned to keeping updated on payer rules should be responsible for updating the prior authorization master list.
Scheduling Staff Updates are Critical
Keeping scheduling staff informed about new procedures that require prior authorizations is essential. Taking this step can significantly reduce the number of patients providers treat before prior authorization approval is received.
A Master List of Prior Authorizations is meaningless unless the information becomes part of the medical record.
Getting prior authorization approval from insurance companies can require many steps. Therefore, it is critical for healthcare groups to establish protocols that are part of patients' medical records.
Lack of clinical documentation is a common reason for denied prior authorization requests. Ensure staff members thoroughly document patients’ clinical data. This information is crucial when submitting an initial prior auth request and critical when billing staff resubmits claims that payers initially denied.
Even with automated solutions, prior authorization remains primarily a manual process. Staff members should have access to a quick reference guide of payer contacts.
They need to document every call so that if another staff member is following up, they will know exactly where things stand.
Staff must track each prior authorization and follow up regularly to ensure the payer has all the needed information. Things sometimes fall through the cracks with payers. It is the responsibility of the billing staff to catch these oversights.
When appealing an inappropriately denied prior authorization, take the time to write a well-organized and concise case. Make sure to include all required documentation and supporting clinical information. Check that any missing information from the original prior authorization is included with the appeal.
Only some patients know the complexities and the time it can take to obtain authorization from a payer. Educating patients about prior authorizations at the beginning of their care will make them more tolerant of delays and significantly reduce their frustration with your group.
Healthcare groups can lighten the growing burden of prior authorization by looking to implement technology solutions to their processes.
Automated Prior Authorization software solutions can significantly reduce your staff's time on prior authorizations.
Below are some features to look for when selecting a solution:
Compatibility with your group's EHR system This enables your staff to access all the necessary information in one place.
Automated alerts are an essential feature of any automated prior authorization system.
Artificial Intelligence (AI) and Machine Learning (ML) An automated prior authorization solution should be able to 'learn' as it processes prior authorizations. You should also be able to add your team's knowledge and experience to the analytics engine of the software.
For more information on selecting an automated prior authorization solution for your practice, check out our blog article ‘Bolstering Your Prior Authorization Processes to Thrive.’