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Importance of automation in prior authorization for practices


Even in today’s digital climate, some administrative staff in the healthcare industry still perform the prior authorization process manually, which is a considerable burden

robot hand holding healthcare icon | © Production Perig - stock.adobe.com

© Production Perig - stock.adobe.com

Delivering first-rate patient care should always be the primary goal of any healthcare organization, but with that comes the complexities of managing healthcare. One central pain point is the prior authorization (PA) process. Even in today’s digital climate, some administrative staff in the healthcare industry still perform the PA process manually, which is a considerable burden with extensive administrative tasks and resource requirements. In fact, physician’s offices have reported spending as much as 14 hours per week on prior authorization, therefore tasking resources with the additional time and effort demands on their workload.

Resolving PA inefficiencies

The time-consuming PA administrative process hits physicians’ offices’ most vulnerable spots – its patients and internal care teams. An American Medical Association (AMA) survey of more than 1,000 physicians discovered that 89% of physicians believe that PAs negatively impact clinical outcomes. Outdated and manual prior authorization (PA) processes negatively impact the patient experience by causing delays in care due to increased administrative tasks and predominately manual workflow processes that reduce efficiencies.These issues contribute to higher burnout and overall staff turnover.

The manual PA process poses challenges to patient care and strains internal care teams, particularly amid industry labor shortages, mental health concerns, and low employee morale. It proves to be time-consuming and expensive for healthcare providers, imposing a heavy administrative workload and causing reimbursement delays that financially burden healthcare organizations.

In addition, the manual PA process is often marred by human error, resulting in unnecessary delays, rejections, or even potential patient safety issues. These issues, combined with insufficient documentation and paper-dominant workflows, frequently result in denied claims, emphasizing the urgent need for automation in the PA process.

The critical need for PA automation today

Automation minimizes the risk of errors leading to denied claims by leveraging technology that uses predefined templates and algorithms to ensure accurate and complete data entry. Automated systems can also help the staff maintain compliance with insurance company guidelines, regulations, and policies. By integrating the specific requirements of different payers into the system, physicians and office administrators can be alerted to any missing information or potential discrepancies in real-time. This ensures that prior authorization requests are submitted correctly, reducing the likelihood of rejections and subsequent resubmissions.

Cost reduction and revenue optimization

Automated systems enable the staff to manage and track prior authorization requests more efficiently, reducing the need to hire additional staff. By minimizing manual interventions and speeding up the approval process, healthcare providers can accelerate cash flow and increase revenue generation.

Data-driven solutions

Analyzing PA data can identify recurring issues contributing to denials, such as submission delays, approval criteria inconsistencies, and payor-specific requirements. In addition, strategic automation can be integrated into workflows to minimize resource allocation for managing prior authorizations, enabling staff to redirect their focus to other critical areas. The synergy between data analysis and automation produces transformative results like improvements to operational efficiency, turnaround time, financial performance, and patient satisfaction. This synergy forms the cornerstone of the use of automation and demonstrates the business case for an effective PA process.

Drive automation with the right partner

Selecting the right automation partner to streamline the PA process is a decision not to take lightly. Physicians must find a partner who understands the intricacies of the revenue cycle and aligns with their specific needs for implementation, integration, and workflow. An effective experienced partner should be able to offer the following solutions:

  1. Deploy Robotic Process Automation (RPA): RPA bots handle repetitive tasks requiring excessive human effort, efficiently gathering information and navigating payer-specific web portals to obtain the PA. RPA helps ensure timely PA requests and approvals to expedite time to cash.
  2. Track payor regulations for PA and update the process accordingly: Staying updated with payor requirements is crucial to navigating the complexities of the PA process. Regular review of claim denials and rejections provides insight into changes across payer requirements that may require regular maintenance within the automation workflow.
  3. Unveil PA denials: A solution must provide complete visibility into why claims were denied during the PA process. Clear visibility allows providers to understand the reasons behind denials, make necessary adjustments, and ensure accurate, complete submissions in the future. Analyzing data from PA denials can drive continuous improvement in the PA process, leading to more successful authorizations and better patient outcomes.

Automating the future

Adopting automation in prior authorization is a worthwhile investment that healthcare organizations should prioritize, as it has transformed the PA process and brings significant benefits to physicians and office administrators alike. The efficiency, accuracy, and compliance offered by automated systems have transformed a once laborious and error-prone process into a streamlined and reliable one. As technology advances, healthcare providers that embrace automation will experience the benefits of enhanced operational efficiency and improved patient experiences while focusing on the delivery of the highest standard of care.

Terri Gatchel-Schmidt serves as Vice President, Consulting at SYNERGEN Health, an end-to-end revenue cycle management solution that ensures the financial success of your practice. SYNERGEN Health transforms a healthcare organization’s revenue cycle ecosystem from end-to-end, generating the revenue essential to the viability of practitioners, enhancing patients’ experience, and enabling financial success.

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