- November 26, 2024
- Posted by: David Smith
- Category: Prior Authorization
Prior authorization process has become an essential yet challenging aspect of patient care. It’s a task that requires meticulous attention to detail. From in-depth attention to insurance policies and the ability to maze through complex documentation requirements-providers are struggling with the Prior authorization process every day.
Though it’s a well-known headache for the providers and clinicians, for patients, it is something worse, poor access to care!
In fact, the AMA’s annual nationwide prior authorization survey has identified that 92% of the providers have reported preauthorization requirements had increased in the past five years. For a quarter of respondents, Prior authorization has led to hospitalization of patients and for 19% [1], delays in Prior authorization led to life-threatening events for the patients. Whereas 9% [2] of the respondents reported their patients faced permanent bodily damage, congenital defect or even death!
Why Do Payers Need Prior Authorization?
Pre-authorization of the clinical services emerged as a cost and utilization management strategy employed by payers and health plans whereby providers must obtain authorization before rendering any service.
Well standards of review are often developed by the plans themselves, based on medical guidelines, cost, utilization and other information.
Payers erect roadblocks allegedly designed for the health system to save expenditures and protect their resources. But when it comes to patient health outcomes, neither them nor providers are satisfied.
The Intricate Web of Prior Authorization
As the AMA survey suggests that prior authorization requirements have been increased over the years, the staff shortages are consistent in this period.
In fact, the healthcare industry has been facing staff constraints for a long time, showing no sign of resolution.
A study on the future of the U.S. healthcare labor market to 2028 [3] has just been released by consultancy Mercer jointly with Light cast at the state level and by metro/micro-statistical areas.
It provides a detailed picture of clinical workforce shortage sensitization and pinpoints which state is best prepared, and which is worst placed in terms of clinical workforce shortage threats arising from changes in market forces, demography and other influential factors.
The key findings of the study are-
- A shortage of about 100,000 critical healthcare workers by 2028
- Shortage of nurse assistants will be severe
- Registered nurse availability will differ across the states
- Modest surplus of physicians nationally
- Variation in compensation might push some workers to move
On top of this ever-changing payer rules, opaque requirements, complex documentation requirements make the pre-authorization process a nightmare for providers like you.
According to AMA survey, 86%[4] physicians used the same reason that prior authorization in decisions may go into overuse of healthcare since patients have to use ineffective care as part of step therapy. Inappropriate utilization comprised the use of the ineffective treatments by 64 percent [4] step therapy, additional office visits at 62 percent and Emergency Department visit at 46 percent [4].
Furthermore, the physicians working on the matter find that prior authorization criteria which define a payer’s approval of a treatment or therapy is often evidence-based.
Providers responding in the AMA survey, sometimes identified the criteria sometimes aligning with prior authorization to evidence revealed in studies by 43 percent [4], while 31 percent [4] said that it rarely or never did.
The labor-intensive, time-consuming and often frustrating tasks of prior authorization led to physician burnout, which deteriorates the quality of care, and your practice becomes prone to errors.
The other side of the coin is as vicious. Not only are medical conditions worsening, but also, patients are struggling with the increased expenses for those initial treatments which they might have left midway due to delays and denials and prior authorization.
On the other hand, the stress and anxiety related to awaiting treatment approval significantly impact the patient’s psychological health as well. Heightened symptoms of existing illness, stress, depression, reduced daily functions are just some of the hurdles to name.
Prior Authorization Solutions with Sun Knowledge
It is probably correct that any attempts to decrease low-value care are worthy, but the reported effects of prior authorization on patient access to care—and, correspondingly, on their outcomes—point to the necessity for a more suitable system.
It is predicted that ePA will reduce the time spent on medical decision-making, as stated in AHIP. Among the providers who reported using the ePA tools, 71 percent [4] said that patients received care earlier than when they filled the traditional prior authorization forms. The time taken to get to a decision was cut from a median 18.7 hours to 5.7 hours.
A strategic healthcare revenue cycle management partner like us can always come in handy while dealing with the challenges of authorization. Our pre-authorization solutions comprise of-
- Verification services
- Documentation services
- Hassle-free claim settlements
- Management of complex coding systems
- Follow-up services
We as a leading prior authorization company offering a number of solutions that address all your billing concerns with your clients across the globe. The dedicated, highly trained team is to assist healthcare providers ease their burden, simplifying the stringent and formerly tedious pre-authorization process so that they can focus on providing the best in patient care.
Resources:
[1] https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
[2] https://www.healthcarefinancenews.com/news/ninety-four-percent-physicians-report-care-delays-due-prior-authorization-ama-says
[3] https://www.mercer.com/en-us/insights/talent-and-transformation/attracting-and-retaining-talent/future-of-the-us-healthcare-industry/#download
[4] https://www.techtarget.com/patientengagement/feature/How-Prior-Authorization-Impacts-Patient-Access-to-Care