Prior authorization (PA) has been a major obstacle in healthcare for years. The PA phase was introduced in the Revenue Cycle Management(RCM) cycle to ensure appropriate patient care and prevent exploitation of healthcare services; PA not only helps to check if the treatment prescribed is covered by the patient's health plan but also confirms if the line of treatment is the most suitable and efficient option. If done right, it definitely streamlines therapy.
Unfortunately, the cumbersome procedures have turned PA into a trap leading to administrative inefficiencies that induce deferrals in patient care. Digitalization of PA can define an auto process that is cued to payer requirements; it will put in place a workflow which includes clean documentation of PA to obtain it real-time.
The traditional method of obtaining PA from the payer before any operation or procedure is time-consuming. All stakeholders -providers, patients, and payers are inconvenienced Physicians suffer a heavy backlog in bill payments for various reasons. First, the PA process may not be followed correctly. Secondly, errors may creep in. Thirdly and most importantly, insurance providers restrict the usage of several medications and procedures and the request for PA may be disapproved in the later stages of the RCM, rather than at inception.
Here is why this happens: Typically, when a physician prescribes a medication, the patient contacts the pharmacist who in turn checks with the insurance plan. The communication in traditional PA procedure relies heavily on phone, fax, and form filling. The wait for approval may stretch from days to weeks. At the end of which the patient is either given the medication or denied it for lack of coverage under PA. Thus PA pursued in the traditional manner can be quite disruptive, cause delays, and add to costs. Furthermore, the patients may not get the treatment advised, leading to poor health.
For patients, there is always a question over what treatments they can or cannot access. For a patient who is dependent on insurance, the probability of getting a PA approval from a doctor with better administrative prowess rather than medical skills is a vexed issue. The lengthy procedure can anyway delay timely treatment. Further, when a patient changes a health plan, or the insurer changes the set of pre-approved treatments, ongoing medical care or “continuity of care” is hit.
Meanwhile, healthcare providers blame PA for 91 per cent of care delays.
According to a survey of physicians by the American Medical Association:
The fear of PA rejection causes confusion in the minds of providers, and they are bound to lose focus on effective patient care.
Delay in PA approval leads to rescheduling of medical procedures, and the need for physicians to put in extra hours. Such deferrals cause unnecessary risk both for the patient and the provider.
Electronic preauthorization (EPA) helps to cut down on time. Approvals can be sought and obtained real-time at the point of care as EPA integrates directly with electronic health records (EHRs).As the time-consuming paper forms, phone calls and faxes are replaced by electronic request, EPA relieves administrative burdens and improves time to therapy.
As the EPA and EHR workflow is integrated, medications, and procedures that do not require PA are immediately identified, and the treatment is speedened. As patient data is already at hand, physicians can devote time and energy to patients, boosting patient satisfaction.
Some utility software features like notifications and dashboards to monitor and control workflow, and make workflow free from manual interventions, make the process smooth for healthcare providers.
There are many EHR systems, and not every EHR is tailored to satisfy PA requirements. Healthcare facilities should adopt EHR systems that are designed with functionality considerations for PAs. Such an EHR would record accurate details of patients, orders, test results, and care provided.
It would not specify actions that are more restrictive than state law, preventing PAs from receiving information on patients treated, restricting access of PAs to relevant functions of the EHR, or mask information on services under PA.EHRs should be designed to identify professional work as it is important for clinical assessment, practice improvement, measuring patient care, and to ensure transparency.
Level of access granted in the EHR system should be modifiable to account for a health professional’s specialty, scope of practice, and privileges. When designed and implemented in a manner that properly accounts for PAs, EHRs can encourage transparency, improve quality, increase patient safety, enhance operational efficiencies, provide cost savings, and enrich patient satisfaction.
Regrettably, most automation solutions provide solutions which address only some pain points of the RCM phase. Fortunately, the PA process includes components which are repetitive and complex, and they are an ideal case for AI. A range of medical services –be they prescriptions, CT scans, elective surgery, or clinical trials are not only repetitive but also complex with high levels of variation. Similarly, the data exchange standards and rule-based architecture for PA varies depending on the practice, services, and health plan. AI can be used to monitor, refine, and predict processes to attain better efficiency.
Many firms have been developing digitalized solutions which leverage both machine learning and AI to speed up the PA process at less cost and no denials. They can integrate with many practice management, hospital records, and EHR systems which allow users to authenticate eligibility and co-payments, enter patient information and speed up patient registration by accessing information on relevant plans.
Such digitalized platforms can be customized to track co-payment, deductibles, and claims. They can be programmed to check for new cases, submit them to the payer, monitor responses, and once authorization is received, submit it to the providers EHR system. They can also recognize improper and under-coded claims. With digitalization and automation, PA can be rendered seamless, leading to operating efficiency and better physician, payer, and patient satisfaction.