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Expert explains why automation is key to prior authorization reform

Article

Automating prior authorization is an investment that every health care organization should consider. As the industry grapples with rapid regulatory shifts and acute staff shortages, a tailored automation strategy is key to enhancing patient care and improving operational efficiency.

This article first appeared on our sister site Medical Economics.

The prior authorization (PA) process poses a significant obstacle to the delivery of optimum patient care. It often imposes significant administrative and resource burdens for physicians and medical staff, as was noted in CNN’s recent reporting1 of UnitedHealthcare’s shift from PA to advance notification for endoscopy services.

Automation in PA is much more than a tech upgrade – it’s a transformative approach capable of delivering many benefits. These include streamlined workflows, reduced approval times, and decreased denial rates, ultimately fostering a climate of transparency among patients, providers, and payers

Automation in prior authorization is much more than a tech upgrade – it’s a transformative approach capable of delivering many benefits. These include streamlined workflows, reduced approval times, and decreased denial rates, ultimately fostering a climate of transparency among patients, providers, and payers.

The inefficiencies of the manual approach, highlighted by denied claims due to insufficient documentation and dispersed information across systems, underline the pressing need for intelligent automation in the PA process.

The imperative of automation in today’s climate

Amid an increasingly complex regulatory environment and chronic staff shortages, the pressure on health care organizations is intensifying. This is precisely where automation has shown its true potential. A recent KLAS survey found that 78% of organizations implementing automated PA have witnessed improved financial outcomes2 and a significant uptick in staff efficiency.

Proactive leaders in health care have already started to harness the power of automated PA processes, showing the industry the path to follow. The daunting pressures of today's health care climate don’t make automation an attractive proposition—they make it a necessity.

The power of automation and risks of inaction

Automation in PA is much more than a tech upgrade – it’s a transformative approach capable of delivering many benefits. These include streamlined workflows, reduced approval times, and decreased denial rates, ultimately fostering a climate of transparency among patients, providers, and payers.

The financial risks are significant for those who remain on the sidelines. A 2021 CAQH report3 revealed that manual transactions in health care, including PA, cost the industry $17.6 billion. This staggering figure underlines the criticality of embracing technology-led solutions in PA.

Harnessing data and automation for enhanced outcomes

A deep dive into PA data reveals recurring issues contributing to denials. These can range from submission delays and inconsistencies in approval criteria to understanding payer-specific requirements. By identifying these patterns, strategic automation can be incorporated into workflows, minimizing resource allocation for managing prior authorizations and allowing staff to redirect their focus to other critical areas, ultimately enhancing patient care.

Moreover, automation's role extends beyond eliminating manual inefficiencies—it accelerates the PA process. Automating routine tasks significantly reduces administrative burdens, paving the way for quicker turnarounds and faster reimbursements.

When we bring data analysis and automation together, the results can be transformative. We can significantly improve operational efficiency, turnaround time, financial performance, and patient satisfaction. This synergy is the cornerstone of an effective PA process.

Selecting the right automation partner

Choosing a partner for automation has significant consequences. Health care organizations must find a partner who understands the intricacies of the revenue cycle and aligns with their specific needs for implementation, integration, and workflow. An effective automation partner for streamlining prior authorizations will:

  • Deploy robotic process automation to ensure timely PA approval
    Robotic Process Automation (RPA) deployment can be a game-changer in prior authorization. RPA bots are designed to handle routine, repetitive tasks that often require excessive human effort. These bots can efficiently gather the necessary information—such as patient details, diagnosis codes, and procedure codes—and navigate payer-specific web portals to obtain the PA, which is then forwarded to the relevant provider.
  • Track payer regulations for PA and update the process accordingly
    To navigate the complexities of the PA process, keeping up-to-date with payer regulations is essential. Different insurers have distinct requirements for PA submission, and minor misunderstandings or oversights can lead to delays and denials. Therefore, part of the PA process involves diligently tracking these requirements and updating the process as needed. Regular review of claim denials and rejections can also provide insight into changes in payer requirements.
  • Provide transparency into PA denials
    Transparency is vital in the realm of PAs. Providers must understand the reasons behind a PA denial to address any problems and avoid future denials. Providing clear visibility into PA denials enables staff to identify and understand common reasons for denials, make necessary adjustments to their processes, and ensure accurate, complete submissions in the future. Data from PA denials can be analyzed and used to continuously improve the PA process, ultimately leading to more successful authorizations and better patient outcomes.Streamline prior authorizations with intelligent automation

Automating PA is an investment that every health care organization should consider. As the industry grapples with rapid regulatory shifts and acute staff shortages, a tailored automation strategy is key to enhancing patient care and improving operational efficiency. By adopting automation, we can effectively sidestep the administrative burdens of the PA process and refocus on what truly matters: providing the best patient care.

References

1. Howard, J. UnitedHealthcare shifts colonoscopy requirements from controversial ‘prior authorization’ to ‘advance notification.’ Published online June 1, 2023. Accessed June 21, 2023. https://www.cnn.com/2023/06/01/health/unitedhealthcare-colonoscopy-requirements/index.html

2. KLAS Research Premium Reports. Automated Prior Authorization 2023: What Impact Do Automated Prior Authorization Solutions Provide? Published online January 23, 2023. Accessed June 21, 2023. https://www.caqh.org/sites/default/files/explorations/index/2021-caqh-index.pdf

3. 2021 CAQH Index. Working Together: Advances in Automation During Unprecedented Times. Accessed June 21, 2023. https://www.caqh.org/sites/default/files/explorations/index/2021-caqh-index.pdf

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