3 Steps to Ease the Prior Authorization Burden

It’s no secret that prior authorization (PA) requirements create a time-intensive burden that delays patient care and takes providers and staff away from their clinical activities only to spend that time with administrative tasks and redundant paperwork. The American Hospital Association (AHA) reported that hospitals, health systems, and post-acute care providers spend almost $39 billion on regulatory and compliance tasks. The AHA Regulatory Overload Report further stated that over 60% of that amount is directly dedicated to medical billing and coverage verification.

While there has been some governmental, payor, and regulatory agency movement towards trying to reduce administrative strain, including CMS’s “Patient Over Paperwork Initiative”, significant change may be elusive. Rather than wait, progressive organizations are exploring the improvements that are available today through automation and artificial intelligence (AI) driven software.

While there has been some governmental, payor, and regulatory agency movement towards trying to reduce administrative strain, including CMS’s “Patient Over Paperwork Initiative”, significant change may be elusive. Rather than wait, progressive organizations are exploring the improvements that are available today through automation and artificial intelligence (AI) driven software.

How Can Automation Impact Healthcare’s Administrative Burdens?

Time and resources are precious in any industry, but especially in healthcare, where your efforts can determine the outcomes for patients and their care. Yet hospital outreach programs, molecular diagnostic providers and remote patient monitoring device organizations are burdened with verifying insurance coverage. The process is often manual, and with approval for treatment, procedures, and medication that can take anywhere from one day to two weeks to obtain payor consent.

With today’s advancements in technology, laboratories, hospital outreach programs, and outpatient lab and molecular diagnostic providers can facilitate patient access and improve their bottom lines through reduced costs and improved revenue capture. Let’s look at three functions that can be positively impacted through advanced AI and automation.

1. Prior Authorization

Manual PAs are estimated to cost about $7.50¹ each to process with providers averaging $83,000² per year for preauthorizations alone. This cost can be reduced to an estimated $1.89¹ per occurrence using an automated PA software and thus free clinical and administrative staff time to focus on the patient experience.

With AI-driven technology, treatment plans can be assessed for individual payor PA requirements, submitted electronically, and monitored for approval or follow-up automatically. Approvals are then routed to the scheduling department in real-time and, if it’s determined that follow-up or exception handling is required, the PA can be still be processed without interfering with staff workflow.

2. Insurance Eligibility Verification & Benefits

Imagine the efficiencies gained by being able to track and confirm precise patient coverage details in real-time? Using an automated, seamless HL7 integration through your EHR/EMR system, you can have information available immediately, including coverage, eligibility, deductibles remaining, and out-of-pocket or annual maximums. As an added bonus, reducing administrative time spent on hold and faxing insurance payers greatly reduces staff frustration thereby improving patient encounters.

3. Patient Pay Estimates

By providing patients with real-time estimates of their portion due, you vastly increase the potential for collecting at or before the time of service. Once the initial visit has passed, it becomes increasingly difficult to collect on portions due from patients. Up to 30%³ of collectible revenue then unnecessarily becomes part of the A/R with the increased costs of billing and collections.

With an automated software generating patient pay estimates, your scheduling staff can notify patients in advance of their appointment to collect those portions due. It’s estimated that up to 90%⁴ of patients are willing to pay before they receive care given a solid explanation of their benefits, the insurance contribution, and their portion.

When weighing the benefits, consider that the financial savings recognized by applying automated and AI-driven software solutions far outweigh the cost for acquisition and implementation, both in FTEs and in captured revenue. Equally important, however, is the reduction in provider burnout and the opportunity to instead spend time providing patient care.

Contact us today to explore leveraging AI and automation in tackling your administrative burdens.