Where can automation and interoperability appropriately accelerate care and eliminate waste?

The prior authorization process (PA) is intended to manage utilization of healthcare resources, reduce overuse or misuse of services, improve quality of medical care, and control healthcare spending. However, archaic and laborious manual prior authorization processes delay and disrupt medical treatment and can have life-or-death consequences for patients, especially during a public health emergency. Interoperability and automation are two technology areas that can lessen the administrative burden and cost for payers and providers while accelerating time-to-treatment and decreasing rework and waste.

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The Healthcare Industry’s Problem with Prior Authorizations

The authorization process is the top issue within the revenue cycle resulting in delayed care, lost revenue, and dissatisfied patients. Data reveals the burden that current, manual prior authorization processes create:

  • Medical practices spend an average of two business days a week per physician to comply with health plans’ inefficient and overused prior-authorization (PA) protocols.
  • One-third of practices employ staffers who spend every second of their working hours on PA requests and follow-ups.
  • Administrative prior authorization processes have been estimated to contribute as much as $25 billion annually to healthcare costs and have been linked to adverse effects on patient care and provider morale.
  • PA requirements are expanding to include new medical services and additional treatments.

Providers and payers commonly follow the Prior Authorization workflow, exemplifying several pain points, as shown in Figure 1.

Prior Authorization workflow

Figure 1 Where could automation and interoperability smooth out this workflow in your department?
Source: https://www.caqh.org/core/prior-authorization

(1) Identifying Prior Authorization Requirements: Workflow Automation is Key

Provider staff must manually review lists of services that require PA. These lists can differ significantly within one health plan and when compared to other health plans. Plus, there is a lack of specificity and uniformity, as well as many lists and requirements information may be out of date.

The retrieval of clinical information required to accompany the PA request is mostly manual as providers are responsible for keeping up with ever-changing payer rules. Conversely, upon submission of medical records to a payer, utilization management (UM) staff are required to review and enter data manually, scan and index submitted medical records.

(2A) Submitting Additional Documentation: Standardize HIPAA Mandated Attachments

As part of submission requirements, providers must often share clinical documentation to prove medical necessity for the services they are requesting. Documentation is submitted in the form of an attachment whose workflow is primarily manual and a source of significant administrative burden. To date, there is no HIPAA-mandated standard for attachments resulting in a lack of direction needed to support the broad use of automation in the attachment workflow. Because of the lack of a standard, most vendor solutions do not offer support, requiring numerous workarounds that providers must support instead.

(2B) Submitting the Prior Authorization Request: Interoperability Among Payers and Providers is Important

Providers use a range of manual, electronic, and partially electronic processes for submitting prior authorization requests to health plans. While manual options, like authorizations by phone, are generally more burdensome and costlier, they result in the most clarity regarding requirements, status, and next steps, given the lack of automation across the entire prior authorization workflow.

Web portals are less efficient given their lack of uniformity and staff time required to manage unique logins for every health plan. While federally mandated under HIPAA, the 5010X217 278 Request and Response is not viable if the provider does not have the system to support it. Vendor solutions must address this gap by working with payers and providers to ensure interoperability and support of federally mandated 5010X217 278 Request and Response.

(4) Communication of Next Steps and Adjudication of Final Determination: Transparency Can be Achieved by Integrating Clinical and Administrative Systems

Health plans lack robust communication channels to update providers about errors promptly, the need for additional information or alert them about the next steps. Once the health plan receives a prior authorization request, most are routed through a manual internal review rather than an automated adjudication process. This drags out the time needed for final adjudication, and further delays patient care as providers must call health plans to determine the status of their request or determine if there is missing or incomplete information.

When the health plan has collected the information needed to decide, it is usually communicated to the provider via a decision notice letter, web portal notification, or phone call. Integration between clinical and administrative systems and effective dashboarding would allow providers and payers to have and give greater transparency, streamlining updates on the status and eliminating delays and gaps to PA decisions.

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Creating a Plan for Automating Prior Auth Workflows & Smoother Data Exchange and Access

Most of these pre-authorization pain points, and many others, could be lessened or eliminated with the integration and consolidation of focused digital solutions that sit in between current platforms. Our healthcare services team has access to automation, interoperability, and process improvement experts and technologies to re-envision and revamp your prior-auth process. Let’s discuss the pain points and bottlenecks that crush your employees and create a roadmap for a streamlined error-free approach.

Peony Jena
Senior Management Consultant

Peony Jena, Senior Management Consultant, joined SDLC Partners in September 2016. With over 9 years’ experience in strategy and healthcare, Peony is a seasoned leader with a focus on product...

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  • Christopher Shipton
    Senior Consultant/CMP, Healthcare Solutions
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