The prior authorization (PA) process healthcare providers endure is a story of unintended consequences. Created as a utilization management tool for healthcare insurance companies to control costs and protect patients from surprise bills, it has increasingly created heavy administrative burdens, increased claim denials and rework, and delays in care for patients. Medicare Advantage (MA) plans have become notorious for their high denial rates. The share of all PA requests that were denied by MA plans increased from 5.7% in 2019 to 7.4% in 2022. PA process challenges, whether related to commercial or government coverage, have a negative impact on providers’ financial performance and cause unnecessary stress for billing teams and patients alike.
Addressing the root causes of process delays, administrative bloat, and claim denials that lead to write-offs is complicated — especially with increasing PA demands from payers. Rules differ from payer to payer and from plan to plan, and the rules change frequently. Typically, the process is highly manual and requires administrative staff to search paper documentation, PDFs, and payer web portals. Physicians and other providers must review the PA requests and medical charts, robbing them of time — 12 hours per week, per physician on average, according to the “2023 AMA prior authorization physician survey” — that could be spent with patients.
If PA is required, providers must track down specifics pertaining to each current procedural terminology (CPT) code applicable to the prescribed treatment. They also must obtain a number assigned by the payer that corresponds to the PA request and include it when the final claim is submitted. The responsibility falls on the provider to continue to follow up with the payer until there is a resolution to the request — an approval, redirection, or denial. Depending on the complexity, the level of manual work involved, and the requirements stipulated by the payer, a PA can take anywhere from one day to a month to process.
Delays Hurt Patients, Providers, and Profits
PA delays can cause problems for both patients and the providers attending to them. Some patients may forego treatment or fail to adhere to prescribed medication. Furthermore, delays can cause unintended consequences that add to the cost of care. Patients may experience an adverse event and seek interim treatment at an emergency department while the PA is under review.
The American Medical Association surveys practicing physicians annually. In its latest nationwide survey, 94% of physicians reported that PA led to delays in patients’ access to necessary care. Seventy-eight percent of physicians reported PA can at least sometimes lead to patients abandoning the recommended course of treatment, with 24% of physicians stating that PA has led to a serious adverse event for a patient in their care.
The burdensome PA process robs providers and the administrative team that supports them of time that would be better spent attending to patients. It contributes to healthcare worker burnout, and the unpredictable process disrupts workflows and hurts administrative efficiency, adding to overhead costs.
Sometimes, PA requirements are not determined until after treatment is complete, resulting in partial or no reimbursement. When that happens, providers must try to collect payment directly from patients, a process that may mean writing off uncollectible patient balances as bad debt.
Real-time PA Technology Can Alleviate the Pain in the Process
Fortunately, there is technology that can dramatically improve the PA process and give doctors back those hours to spend on patient care. Implementing tools that automate manual tasks can reduce the administrative burden, improve financial performance, and serve patients better with timely care and a more frictionless experience.
With the number of procedures requiring PA expected to grow, finding a way to mitigate tedious, time-consuming, manual tasks through automation is urgent. Best-in-class PA tools leverage artificial intelligence (AI) to automate much of the process in real time, eliminating the need for faxes, phone tag, and emailing.
Building upon automated eligibility and patient financial responsibility systems, providers can add AI-enhanced, real-time PA technology to drive the end-to-end PA process as early in the revenue cycle as possible. Doing so reduces the likelihood of errors, slashes the amount of manual work wasted on tedious tasks, and accelerates patient care. It also adds invaluable functionality, such as the ability to automatically identify whether PA is required and to determine the optimal submission route.
A fully integrated, end-to-end approach includes:
- A master patient index (MPI) that can identify each unique patient
- Direct, real-time connections to most payers
- An extensive library of payer rules that synchronizes eligibility and PA rules
- Integration with workflows and systems like EHR, LIMS, health information system (HIS), and revenue cycle management (RCM) solutions
- A self-learning system that uses artificial intelligence (AI) to dynamically update automated workflow and rules engines based on the actual responses and results from submitted PAs
- Ability to integrate with automated revenue optimization tools, such as demographic verification, insurance discovery and verification, self-pay analysis, and deductible monitoring
- Ability to validate a PA request against payer guidelines, automatically submit it, and then receive instant decisions from the payer.
By streamlining the PA workflow, patients can access care faster, with the added benefit of understanding and planning for their out-of-pocket financial responsibility. They may also reduce or prevent hospitalizations that could add significant additional expenses.
Although PA is complex, using an AI-enhanced, real-time tool to automate manual tasks can lighten the administrative burden and put provider focus back where it belongs: on the patient. The right technology can provide game-changing efficiency, certainty, and stronger financial performance for providers and healthcare systems.
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About Us
ZOLL Data Systems provides software and data solutions that help RCM teams and healthcare providers improve financial, operational, and clinical performance. ZOLL AR Boost is the comprehensive revenue cycle management optimization solution suite that automatically finds, corrects, and verifies patient and payer information. It helps healthcare financial teams capture more revenue, reduce administrative burden, and improve the patient financial experience. The solution delivers accurate, actionable data to reduce claim costs, drive self-pay and high-deductible conversions, and improve revenue collection compliantly. Visit the website to learn more about our centralized, AI-enhanced Prior Authorization tool.
