By reimagining and optimizing prior authorization, health systems have a unique opportunity to revolutionize patient experiences, minimize administrative burdens, and ultimately pave the way for a more responsive and patient-centric healthcare landscape.
Streamlined Communication and Collaboration
In an ecosystem consisting of healthcare providers, payers, and patients, streamlined patient access is the foundation for enabling patients to get the care they need as quickly and simply as possible. For example, ensuring information from an electronic health record (EHR) can flow seamlessly and bi-directionally as part of the prior authorization process can reduce delays, provide faster authorization decisions and ultimately speedier access to essential medical treatments and services.
The current challenge is that healthcare staff must spend exorbitant amounts of time copying and pasting information from EHRs to dozens of payer websites multiple times daily. Or, faxing information while also navigating payer rule changes that can evolve by the minute. Next in the communication chain is tracking the status of these requests and, finally, communicating with patients and providers. Each of these is an opportunity in the prior authorization lifecycle for dramatic improvement in both communication and collaboration.
Technology platforms that offer automation by eliminating individual payer fax and web portals can be a catalyst for improving communication and collaboration between providers, patients and health systems.
Increased Operational Efficiency and Reduced Administrative Burden
Understanding where the greatest cost and complexity is in your current patient access workflow is key to determining where your organization can begin to revamp processes. This could involve conducting workflow audits (how is your staff spending their time and where are the bottlenecks?) to collecting feedback from key stakeholders (providers, administrative staff) to understand their pain points, communication challenges and where they’re doing the most repetitive work.
The most likely scenario is that a truly comprehensive view of how your organization is tackling the prior authorization process from the top down—including being able to analyze data analytics that considers turnaround time from payers, does not exist. As a best practice it is worth putting in the effort to identify the inefficiencies in the current workflow. Putting in this work upfront will lead to a faster, more successful implementation of a technology solution that offers automation.
True automation for prior authorization should eliminate manual workflows and duplicate work, decrease errors, and ultimately create operational efficiencies. The net result can mean reallocating staff to more mission-critical tasks while avoiding burnout and frustration. The ability to then evaluate staff productivity once the automation is in place will also increase overall operational efficiency.
Enhanced Patient Experience and Satisfaction/Faster access to patient care
There is a direct and well-documented correlation between prior authorization automation and patient satisfaction and access to care. The 2022 prior authorization survey by the AMA found that 94% of physicians reported care delays due to prior authorization and 33% reported that PA has led to a serious adverse event for a patient in their care.
Automation significantly speeds up the prior authorization process by eliminating manual tasks and accelerating the exchange of information between healthcare providers and payers. Reducing administrative delays translates into shorter patient wait times, enabling them to access necessary medical treatments and services more promptly. Faster access to care can make a significant difference in patient outcomes.
Patient satisfaction is also on the line. Whether it is reducing wait times or improving communication methods (for instance, by receiving updates through their electronic health record, email or even SMS messages), clear communication can help manage patient expectations and foster better trust in the healthcare system as a whole.
Improved Compliance and Risk Mitigation
Prior authorization submission automation ensures consistent adherence to predefined protocols and guidelines. This standardization helps in achieving compliance with regulatory requirements and industry standards. Automated prior authorization submission can be programmed to follow specific rules and regulations, reducing the likelihood of human error, and ensuring that each authorization request aligns with the necessary criteria.
Prior authorization automation platforms can also enable audit preparation and prior authorization traceability Prior authorization automation provides a robust audit trail, allowing healthcare organizations to track and trace every step of the authorization process. This audit trail is invaluable for compliance purposes, as it enables organizations to demonstrate adherence to regulatory requirements. In the event of an audit or review, having a detailed and easily accessible audit trail aids in risk mitigation.
Finally, these automated systems can analyze data to identify patterns and potential risks associated with prior authorization requests. By flagging unusual trends or anomalies, healthcare organizations can address potential compliance issues before they escalate.
Cost Savings and Reducing Administrative Overhead
Put simply, less manual work means streamlined workflows, faster processing times and increased overall efficiencies, which dramatically affects the bottom line. Healthcare organizations that take advantage of automation technology can allocate resources more effectively. A reduction in administrative overhead, including staff time and resources dedicated to paperwork, phone calls, and follow-ups, translates into direct cost savings for healthcare organizations.
With automation handling routine tasks, healthcare organizations can optimize the allocation of human resources. Staff previously dedicated to manual authorization processes can shift focus to more value-added tasks, improving overall productivity and potentially avoiding the need to hire additional administrative personnel.
However, the cost savings are realized in more than just administrative overhead. Minimizing denials by ensuring authorization requests comply with payer guidelines is another tangible benefit of prior authorization automation. Accurate billing and authorizing all eligible services can also prevent revenue leakage, leading to more accurate reimbursement and revenue capture. Once armed with accurate and timely data from prior authorization solutions, healthcare organizations are primed to negotiate favorable terms with payers, including reimbursement rates.
Embracing the transformative power of prior authorization solutions not only revolutionizes internal processes but also elevates the overall quality of patient care, fostering a more responsive, patient-centric, and financially sustainable healthcare landscape.
Dr. Steve Kim
As co-founder and CEO, Dr. Kim leads Valer’s overall mission and strategy. With more than 20 years of medical experience and a passion for studying value-based care outcomes, Dr. Kim’s expertise has been vital in navigating the evolving complexities of the healthcare industry and identifying the administrative roadblocks and bottlenecks delaying access to care. Before his transition into business entrepreneurship, Dr. Kim was an Assistant Professor of Urology at the University of Southern California’s Keck School of Medicine, where he served as the Director of Clinical Research Informatics for Children’s Hospital Los Angeles in addition to practicing pediatric urology.