How To Implement An Electronic Prior Authorization Solution To Reduce Costs and Prevent Care Delays

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By Dennis Zanetti

Medical authorizations can be one of the most frustrating barriers to efficient and effective patient care. According to the American Medical Association (AMA), participants often wait an average of three days for a prior authorization (PA) decision from their health plan, leading to care delays in 92 percent of cases and causing 75 percent of participants to abandon treatment. The complex, labor-intensive authorization processes also create tremendous administrative and cost burdens on providers and payers. Electronic prior authorization technology promises to change this by automating authorization workflows and streamlining communication between providers and payers.

The commercial healthcare industry stands to save an estimated $9.8 billion by adopting electronic transactions for the most common claims-related administrative processes, including prior authorizations. In a Consensus Statement, health industry groups, including the AMA and leading health plans, agree that the adoption of electronic prior authorization transactions is one of the top strategies to improve process efficiency. While implementing an electronic authorization solution is not without challenges—including the consideration of various use cases, complex policy, clinical data and requirements—they can be overcome by focusing on high-level objectives that promise to deliver optimum results. Objectives to help determine the right approach should include the following:

Reduce Administrative Burden 

Physicians average 29.1 PAs per week and their staff spend about 14.6 hours to accomplish the associated workload. An effective electronic prior authorization solution should guide and automate as much of the pre-authorization workflow as possible to reduce the work required from participants. For instance, leveraging automation, plans can implement business rules in their electronic solutions that can help pre-process or automatically approve a simple case authorization before it reaches a final submission. These business rules can help providers understand what data is required and help determine whether a prior authorization is even needed based on the details being submitted. 

Clarify Health Plan Requirements and Policies to Users

Prior authorizations are required for many services, including medical supplies and equipment (DME), Home Health Care, Behavioral Health, Infusion Therapy, High Tech Radiology, and a wide variety of inpatient emergent and outpatient procedures. Policy requirements vary by health plan and product, making it difficult for providers to understand what data is required when submitting an authorization request.  A flexible solution can auto-fill information about the patient, guide the user to supply the data that is required for the specific type of service request and send the data to the health plan for review.  Collecting all necessary data electronically at the time of submission creates a more positive user experience for the provider and makes processing by the plan more efficient thereby reducing the need for follow-up requests for the required information and shortening the time to receive approval.

Streamline Communication

Prior authorizations often require multiple interactions between providers and plans, taking time and adding expense to the business of care. An electronic solution should enable a plan to request exactly what is needed from the provider, and give the provider the ability to respond with that information electronically. An automation tool can coordinate these workflows and provide a consolidated view of the case that combines the information submitted by the provider with responses from the health plan. The electronic workflow can also automate the simple task of obtaining real-time authorization information and status updates.  These electronic workflows reduce and often eliminate unnecessary back-and-forth between parties, reducing the burden and costs for the provider and health plan, and expediting care for the patient.

Create an Efficient Submission Process and Follow-Up

Even with automation, prior authorizations are not a one-and-done transaction. Follow-up workflows, such as status checks, submission of additional information and appeals are often involved. An electronic prior authorization solution should support clinical attachments, enabling users to submit a request and subsequently submit supplemental documentation critical to the review, by tagging attachments with specific data attributes that make it easy for the plan to associate the attachments with the original request.

By automating workflows, streamlining communication, and clarifying plan and policy requirements, you can implement an electronic prior authorization solution that significantly reduces frustration and administrative burdens and results in more effective and timely care for patients. To learn more download NantHealth’s whitepaper, NaviNet® Implementation Challenges for Electronic Prior Authorizations

About the Author

Dennis Zanetti is the Principal Product Manager for NaviNet Open Authorizations and Claim Management at NantHealth and has been delivering technology solutions to healthcare payers for over 20 years.

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