Improving The Efficiency Of Prior Authorization In Medical RCM

Before insurance companies are able to pay for medical procedures, they require the medical practitioner to issue a sign to verify that the patient is receiving said treatment. The practitioner then acquires prior authorization (PA) and can start treatment for their patient without having to worry about whether the patient’s insurance plans would cover their services. PA is an important aspect of the revenue cycle management (RCM) and mismanagement can lead to heavy costs for you as a healthcare provider or your patient. Therefore, here are some methods that would make prior authorization in medical RCM more efficient.

Delays in the PA Process

Currently, the manual process of conducting prior authorizations heavily slows down the rate at which patients can receive care. It has been reported that almost two-thirds of physicians recalled prior authorization taking up at least one business day to be processed by insurers, and some even reported having to wait over three business days. This sort of delay is detrimental to both the patient and your RCM because it results in patients abandoning a proposed course of treatment.

Automation Optimizes the Process

Healthcare providers may consider using clinical decision support automation tools which aid in the identification and recommendation of a treatment or medication prescription based on standard clinical guidelines. These will mitigate the need for PA.

According to the Council for Affordable Quality Healthcare (CAQH), only 12% of PA requests are submitted electronically to insurance payers. Automation of PA would cut back on the time and effort needed to submit a properly documented request as the automated technology can help to verify the eligibility and benefits of a unique patient in real-time and facilitate smooth communications for all parties. The adoption of this electronic transaction should hence eliminate the manual work needed for the PA process. Electronic prior authorization will no doubt be a much more time and cost-efficient method to handle the process.

Get Into the Gold Card System

Physicians who are steadfast in adhering to an insurer’s requirements for prescribing treatments and medications sometimes gain the added benefit of not needing to receive prior approval.

The requirements for gold-card physicians differ from insurer to insurer, but following an industry standard should work well enough. Physicians on average spend almost 15 hours a week on attaining prior authorization, and being able to reduce this duration by half would allow them to gain a lot more time to focus on delivering care to their patients.

Increased Transparency

Miscommunications between the payers and healthcare providers can be frustrating to deal with and lead to even more delays. Therefore, it is imperative that healthcare providers know which services and prescriptions require a PA, and provide the proper documentation for it. The guidelines can sometimes be found on the insurer’s website.

To further streamline this process the Centers for Medicare & Medicaid Services has started an initiative that makes the process of communicating between providers and the payer’s system more direct and efficient by having an electronic health record system determine if a prior authorization is required.