Automated Prior Authorization for Faster Approvals

For a second, imagine a scenario where you need a crucial healthcare medicine or treatment and the last thing you want to be entangled in a bureaucratic maze. That’s where prior authorization comes into play, helping you access the care you need while ensuring that healthcare providers and insurers keep costs under control.
On average, each physician has to complete 43 prior authorizations per week. Traditional prior authorization leads to problems, including heaps of paperwork, data extraction from medical records, and verification of details. That means delays in getting healthcare services in time and, you guess it right, extra healthcare costs. Automated prior authorization can streamline the whole process and make it easier for everyone involved while enhancing the care you receive. So, why give it a try?

Understanding What is Prior Authorization?

Prior authorization in healthcare serves a crucial purpose. It ensures the patient receives the most appropriate and cost-effective care, aligning treatment plans with established guidelines and payer policies. The prior authorization process aims to control costs, reduce unnecessary utilization, and improve patient outcomes by requiring providers to obtain approval before delivering certain services or medications.

Challenges of Traditional Prior Authorization

Despite the benefits of prior authorization in healthcare, the manual process can significantly burden healthcare providers. The sea of paperwork, faxes, and emails can lead to hours or even days of work to get the necessary approvals. This not only diverts the focus from patient care but also leads to treatment delays, increased treatment costs, and a negative impact on the patient experience. A more efficient system is needed.
The limitations of the manual approach include –

1. Administrative Burden

   According to AMA prior authorization surveys, healthcare providers spend around 12 hours each week completing prior authorization. The manual prior authorization process requires healthcare providers to gather detailed clinical data, complete various forms, and submit them for approval, leading to delays.

2. Inadequate Communication Options

   The manual prior authorization process is hindered by outdated communication methods like faxes, phone calls, and legacy systems, leading to delays and errors such as lost faxes and miscommunication.

3. Patient Dissatisfaction

   In a survey report, around 78% of physicians stated that delay in prior authorization leads to treatment abandonment. This prolonged wait time impacts the patient experience and might lead to lower patient retention for healthcare providers.

4. Lack of Standardization

   Each insurance company may have its rules, forms, and requirements, making it challenging for providers to navigate the system efficiently. The absence of standardization means that healthcare organizations must constantly adapt to varying demands, which can lead to errors, inconsistencies, and delays.

5. Financial Strain

   Denied or delayed prior authorizations can financially impact healthcare organizations. If denied after services are provided, reimbursement becomes challenging, causing economic losses. Even approved delays disrupt the revenue cycle and create cash flow issues.

Automated Prior Authorization- How does it help?

AutomationEdge’s Automated prior authorization in healthcare involves using technologies like AI and automation to resolve prior authorization challenges. Let’s see how prior authorization automation solutions work for healthcare providers-

1. Automated Data Collection and Verification

   Healthcare providers must have critical documents like patient medical records and insurance documents to verify the prior authorization. Automated prior authorization solutions simplify this workflow by-

   1. Automatically connecting to electronic health records (EHRs)
   2. Extracting the necessary patient details, medical history, and relevant clinical documentation
   3. Reducing the administrative burden for healthcare providers and enabled them to focus on patient care.

2. Rule Based Decision Making

   Automated prior authorization systems use AI algorithms to-

   1. Analyse and interpret complex payer policies, clinical guidelines, and coverage criteria.
   2. Quickly evaluate whether a prior authorization request meets the requirements for approval.
   3. Make informed, evidence-based decisions that align with payer expectations and clinical best practices.

3. Electronic Submission and Adjudication

   Healthcare providers must submit authorization requests to the provider for approval to initiate treatment. Utilizing prior authorization automation services, healthcare providers can-

   1. Submit requests autonomously to the payer system with real-time adjudication
   2. Allows for the instant transfer of prior authorization requests and the payer’s system’s immediate processing of those requests.
   3. Receive decisions in real time, instead of waiting days or weeks for approval

4. Automated Approval and Denial

   Automated prior authorization systems can accelerate the turnaround time for prior authorization requests, enabling healthcare providers to move forward with treatment plans more quickly. It can

   1. Generate approvals or denials automatically based on pre-defined rules
   2. Recognize when a request meets all necessary conditions for approval
   3. Triggering an automatic decision without requiring further manual review. This capability dramatically

Embracing the Future of Healthcare with Automation

As the healthcare industry grapples with the complexity of prior authorization, adopting an automated prior authorization system has become a strategic imperative. Prior authorization process automation solutions reduce the administrative burden and improve healthcare organizations’ financial performance.

The streamlined processes and faster approval times translate to more timely care, improved patient outcomes, and a stronger financial position for healthcare organizations. As the industry evolves, adoption of prior authorization automation will be essential for delivering more efficient, cost-effective, patient-centered care. The future of healthcare lies in automation, and those who adopt it early will provide superior care while optimizing operational performance.