Streamlining Prior Authorizations for Better Health Outcomes July 19, 2024
The healthcare industry faces a critical challenge: approximately 78% of providers report that prior authorization (PA) procedures sometimes cause patients to abandon their treatments. This issue underscores how PAs have shifted beyond administrative headaches into becoming one of the most significant barriers to effective patient care.
Efficient PA processes are vital for both patients and healthcare providers. For patients, streamlined PAs mean quicker access to necessary treatments, reducing the risk of treatment abandonment and improving overall health outcomes.
For providers, efficient prior authorization processes minimize administrative burdens and improve workflow efficiency. Such solutions allow providers to dedicate more time and resources to direct patient care, enhancing treatment effectiveness while reducing unnecessary delays.
Manage Prior Authorizations Efficiently
Understanding Prior Authorizations (PAs)
As you know, health insurance companies or “payers” use prior authorization to determine whether they will cover a prescribed product or care procedure. This process often involves a sweeping review of the medical necessity of the healthcare service or medication.
The goals of PAs cover:
- Controlling care costs by ensuring that treatments and medications are necessary and appropriate before they are covered by insurance.
- Ensuring patients receive treatments that align with current medical guidelines and standards.
- Helping prevent the overuse or misuse of expensive or potentially harmful treatments and medications.
- Performing a complete review of the patient’s treatment plan improves coordination and prevents unnecessary treatments.
The Problem with Traditional PA Processes
Traditional PA processes are often manual and time-consuming, requiring significant paperwork and phone calls. The key to a successful preauthorization is accurately providing Current Procedural Terminology codes. The challenge here? You must determine the correct procedural code before the service is provided and documented.
Other issues include:
- The time taken to receive PA approval can delay the initiation of necessary treatments, adversely affecting patient care.
- The need to frequently follow up with insurance companies adds to the workload of healthcare providers and their staff.
- Time and resources that could be spent on patient care are diverted to managing PA requirements.
Implementing electronic prior authorization (ePA) systems can address many of these issues, leading to better patient outcomes and more efficient care delivery.
The Impact of Inefficient PAs on Healthcare
The administrative hurdles associated with PAs tend to overwhelm patients. These scenes can lead to patients giving up on their treatment plans, which means they don’t stick to their prescribed treatments.
When that happens, health issues worsen, hospital visits increase, and overall health outcomes take a hit.
Increased Administrative Burden
Approximately 61% of healthcare providers frequently engage in “peer-to-peer (P2P) reviews” with insurance representatives. These reviews consume valuable time, disrupt patient care, and increase administrative burdens and costs. Switching to prior authorization automation can make things smoother, letting providers focus more on their patients.
Delayed Patient Care
PA can really slow things down for patients needing care. Doctors have to wait around 14 days for insurance approval before giving out meds or doing procedures, which means patients wait longer for treatment. These delays can make health problems worse and keep patients in pain longer. Streamlining the PA process is critical to ensure patients get the timely care they deserve.
Best Practices for Streamlining Prior Authorizations
Improving the prior authorization process involves adopting ePA software and implementing best practices that prioritize clear communication. These efforts aim to expedite approvals, alleviate burdens for providers and patients alike, and enhance the timeliness of quality patient care.
ePA for Efficient Prior Authorizations
Imagine a world without endless paperwork and phone calls for prior authorizations. Electronic prior authorization (ePA) makes this a reality by integrating with EHR systems. This advanced system minimizes the reliance on manual tasks, ensuring accurate CPT codes and streamlining the PA process.
In addition, the CMS Interoperability and Prior Authorization final rule (CMS-0057-F) will significantly enhance the transparency of prior authorization processes. This rule promotes the adoption of ePA by introducing a new measure for the Merit-based Incentive Payment System (MIPS) under the Promoting Interoperability performance category.
In 2026, providers can expect specific explanations for denied prior authorization decisions. This requirement aims to improve communication and transparency among payers, providers, and patients, ensuring providers have precise information to rectify denials.
Forming Clear Communication Channels
Optimizing prior authorization workflows involves creating streamlined communication channels between the following:
Providers and Payers: Effective communication between providers and payers includes accurately submitting CPT codes and complete medical documentation. Implementing ePA systems that integrate with electronic health records and regular updates can help address discrepancies quickly.
Providers and Patients: Providers must set realistic expectations for approval timelines and ensure patients are informed about the information they must submit. This transparency helps manage patient anxiety and frustration.
Payers and Patients: Payers should provide timely information to patients regarding the status of their PA requests, including reasons for any delays or denials. Clear, patient-friendly communication can help demystify the PA process and empower patients to participate in their care.
Takeaway
Getting prior authorizations right is critical to smoother healthcare and better patient results. Optimized PAs empower you to prioritize patient care by streamlining administrative burdens, using integrated ePA tools, and creating communication channels, ensuring prompt access to treatments and superior health outcomes.
Tap Into Our Expertise
Ready to optimize your prior authorization process? With 5 Star Billing Services, you benefit from a team of trained medical coders who excel in precise CPT coding, coupled with advanced prior authorization software that is EHR-integrated and enhances our workflow efficiency.
Every clinic has unique needs, so we offer flexible solutions. Whether you require continuous support or temporary staffing, our skilled medical billing and collection team is here to assist you. Let us help you streamline your PAs and improve your patient care.