4 Best-Practice Steps to Automate Prior Authorization
Preventing no-authorization denials and getting patients timely, quality care is no easy feat. As payers increase prior authorization requirements, providers struggle to hurdle escalating barriers to scheduling care, incurring millions of dollars in administrative costs and lost revenue.
Worse, patients are caught in the crossfire. While payers say the intent of prior authorization is to control healthcare costs, 1 in 3 physicians say prior authorization requirements have led to a serious adverse patient event.
Why Providers Need Intelligent, Automated Prior Auth
Despite the 278 transaction standard readily available for years, and the tremendous cost savings adopting electric transactions would bring, insurers continue to maintain arcane, convoluted prior authorization processes. Hospital groups are calling for government oversight to enforce the use of electronic transactions and to regulate payer response times, but in a time where hospitals are drowning in staffing shortages and managing constricted budgets, they can’t afford to wait for a lifeline.
Instead, providers have looked to technology companies to build automation tools using robotic process automation (RPA) and intelligent rules engines to navigate the ever-changing labyrinth of payer portals, rules and requirements. Many EHRs provide work queues for staff to manually complete prior authorization processes, which still rely heavily on human intervention—putting a strain on short staffed departments. Others solve for parts of the problem, one for determination and another for retrieval.
It doesn’t have to be that way. Using intelligent automation, technology can solve for determination and retrieval.
4 Best-Practice Steps to Automate Prior Authorization
Step 1: Demographic Audit
It’s critical to have automated quality assurance measures in place to audit patient data before prior authorization submissions.
An integrated first step of the prior authorization process, quality assurance:
- Automatically audits 100 percent of patient registrations to identify and prevent financial and administrative errors
- Alerts staff in work queues with errors and payment risks along with instructions for resolving issues
- Automatically re-audits registrations after any changes
- Uses pattern recognition analysis to continuously update automated rules engine to prevent recurring errors and related rework
Step 2: Verify Patient Benefits
Real-time eligibility verification consists of two levels of automation: eligibility verification, plus benefit mapping. An intelligent rules engine analyzes remit data and isolates likely denial-causing payment risks before they occur.
Real-time eligibility:
- Verifies benefits on 100 percent of accounts
- Delivers general and targeted service verification
- Automates batch and manual real-time submission
- Verifies self-pay patients
- Detects found coverage and coverage change
- Provides benefit threshold alerting
- Alerts coordination of benefits
- Delivers RTE, 270/271, HL7 transactions
- Enables benefit post-back to EMR
Step 3: Determination
Arguably the most critical and time-consuming step in prior authorization, hospitals dedicate a significant number of resources to determine when an account requires authorization. Automating determination reduces time spent on the phone, at the fax machine and searching payer websites to get patients authorized for the services they need—faster and with fewer denials.
Automated determination:
- Automatically determines if authorization is needed using rules that are payer- and employer-specific to ensure rules are as current as possible to predict and prevent denials
- Offers flexible options for grouping and sorting work to meet the unique needs of each customer (e.g., by payer, patient alphamix)
- Notifies staff within their work queues when authorization is needed
- Enables staff to easily look up when auth is needed by payer to reduce manual processes
Step 4: Retrieval
Automating retrieval eliminates the need to manually check status on payer portals. Intelligent automation can do the work for you, monitoring response status and retrieving the authorization or denial number, along with additional documentation requests.
Automated retrieval:
- Eliminates manually checking status on portals
- Delivers automated responses into staff work queues, including auth status, denial number or instruction if further documentation is required
- Enables clinical staff to proceed to service more quickly with less staff resources
- Eliminates time on hold, waiting for returned phone calls and manual updates to spreadsheets
- Allows staff to reallocate time to managing submissions to improve accuracy and likelihood of approval
Providers can’t afford to wait for government intervention to regulate prior authorization. Using intelligent, end-to-end automation to automate the four best-practice steps of prior authorization reduces costs, alleviates staffing challenges and gets patients the care they need when they need it. Contact us to learn more about our prior authorization solution.