Do you experience delays in patient care and get frustrated by the time-consuming and costly administrative work of the prior authorization process? If so, let the new technology solutions help improve the status of your requests.
We will know more about prior authorization, its importance, and its process. We will also touch base on the challenges when implementing the new suggested technology solutions to the pre-authorization process.
Prior Authorization: Its Importance in Healthcare
Prior authorization (PA) is a necessary step in the healthcare system. It ensures patients receive the most appropriate and cost-effective care. At the same time, insurance companies manage healthcare costs.
Challenges Healthcare Providers Face
The first challenge is the administrative burden it places on healthcare providers. To obtain a prior authorization, you have to fill out a lot of paperwork, make a lot of phone calls, and wait a long time for approvals. As a result, it can delay patient care and frustrate healthcare providers and the patients.
Another challenge is that the PA process can be confusing and complex, thus creating potential errors. This is because different insurance companies require different forms and procedures.
Finally, healthcare providers, in effect, face accuracy challenges, such as incomplete or incorrect information. It can lead to denials of PA requests or inappropriate care for patients.
Understanding Prior Authorization
Prior Authorization: Definition and How It Works
Prior authorization is a process in which a healthcare provider must get permission from a patient’s insurance company before prescribing or giving certain medical procedures, treatments, or medicines.
When a doctor wants to do an operation or give a drug that needs prior authorization, they must make a request to the patient’s insurance company. Normally, the request contains information about the patient’s medical background, the recommended course of action or prescription, and any other pertinent information.
After reviewing the request, the insurance company decides if the patient’s insurance plan covers the proposed service, treatment, or medication. The insurance company may also think about other treatments or medicines that may be less expensive or better for the patient.
However, a denied request requires the healthcare provider to provide additional information or seek alternative treatments.
The Role of Insurance Companies and Healthcare Providers
In the prior authorization process, the role of insurance companies is to review and approve or deny requests. They make sure the care given to the patient is appropriate.
Meanwhile, healthcare providers must submit requests and provide the necessary supporting information. These include medical records, test results, and other documents.
Both should work together to improve communication and standardize processes. For example, insurance companies provide clear guidelines for PA requests and standardize the approval information. Healthcare providers, on the other hand, provide complete and accurate information upon submission.
Technology’s Role in Prior Authorization
Technology plays a significant role in streamlining the prior authorization process for healthcare providers. It can also improve the process’s speed, efficiency, and accuracy.
With this purpose in mind, we listed the following suggested technology solutions to automate and simplify the PA process:
Electronic Prior Authorization (ePA)
ePA is one of the most promising technology solutions. It allows healthcare providers to submit PA requests electronically, rather than through manual processes. It can also be integrated with an electronic health record (EHR) to easily access patient information and medical history.
Artificial Intelligence (AI) Tools
In addition to ePA, there are several emerging AI tools developed by various companies to help speed up the prior authorization process. One example would be the AI tool that can quickly evaluate whether the required services will be covered by the health plan through clinical reviews powered by artificial intelligence.
Other Suggested Technology Solutions:
A good example is patient engagement tools, such as patient portals and mobile apps. These give patients immediate access to their PA requests and approvals, so they can be more involved in their care and know more about it.
Another example is standardization and interoperability to simplify the process. Standardization involves developing common standards for requests and approvals, while interoperability seamlessly integrates different healthcare systems to share patient data and information.
The Benefits of Using Technology in the PA Process
The current pre-authorization process consumes time and is intense on labor, requiring significant administrative resources from healthcare providers and insurance companies. However, streamlining it through ePA and AI tools can save costs.
Automating the process and reducing manual tasks reduces the time it takes to complete it. As a result, it can lead to faster decision-making, improved efficiency, and better patient care.
Integrating the prior authorization process with electronic health record (EHR) systems can make PA decisions more accurate, which can lead to better outcomes for patients.
Challenges of Implementing Suggested Technology Solutions
Lack of Technical Expertise and Resistance to Change
Not all healthcare organizations have available technical expertise. Changes can be difficult due to concerns about an increased workload or a fear of the unknown.
To address these challenges, providers should invest in additional training for staff. This education can increase staff confidence in using the new technology solutions. Or they can hire outside consultants like Phoenix Virtual Solutions to help with implementation.
Integration with Existing Systems
Integrating new technology solutions with existing EHR and other healthcare technology systems can be challenging. It can also add to the cost and complexity of implementing new technology solutions.
Collaboration between healthcare providers, insurance companies, and technology vendors can help address this challenge. They need to invest in additional IT infrastructure and ensure that the new technology solutions are compatible with existing systems.
Regulatory and Legal Issues
Finally, regulatory and legal issues need to be addressed when implementing new technology solutions for prior authorization. These solutions should comply with Health Insurance Portability and Accountability Act (HIPAA) regulations and other legal requirements to address this challenge.
An Example of Successful Implementation
In early 2020, America’s Health Insurance Plans (AHIP) initiated the Fast Prior Authorization Technology Highway (Fast PATH) program. Its purpose is to gain a deeper understanding of the potential effects of ePA on patients and healthcare providers.
With this purpose in mind, six payers participated in the year-long project. These include Blue Shield of California, Cigna, Humana, Cambia Health Solutions, Florida Blue, and WellCare, now Centene. Availity and Surescripts served as health IT partners, while third-party RTI International evaluated the outcomes. Meanwhile, Point-of-Care Partners provided guidance throughout the project.
After ePA was put in place, the total number of prior authorizations went up by 34%. A third of these transactions were completed in two hours or less, compared to 24 percent of prior authorizations that took two days or more to complete.
Future of Prior Authorization and Technology
This technology is a decentralized, secure way of recording and sharing information. It can help make things clearer for everyone and lower the chance of mistakes and inconsistencies. For instance, storing a patient’s medical records on a blockchain allows healthcare providers to fill out PA requests more easily.
These AI algorithms can analyze large data volumes and make predictions based on that data. It can also help improve accuracy. As a result, it allows providers to refrain from submitting requests that are likely to be denied.
Natural Language Processing (NLP)
This technology can automate repetitive tasks to save time and reduce administrative burdens. In the context of prior authorization, it can make the PA process more manageable, such as filling out PA requests and following up on their status.
For healthcare providers to give their patients immediate, high-quality, efficient care, they need to streamline the prior authorization process. But the current process can be cumbersome, forcing healthcare providers to spend significant time and resources on administrative tasks.
Phoenix Virtual Solutions will help you with your prior authorization needs! Leave the administrative burdens of prior authorization to our team of experts.
Our HIPAA-trained Prior Authorization Specialist can work collaboratively with healthcare providers to identify areas where you can apply new technology solutions for your medical practice.
Contact us today to simplify your prior authorization process and learn more about our comprehensive range of services.