How Prior Authorization Affects Patient Health Outcomes

Prior authorization is a well-known headache for healthcare providers, contributing to excessive administrative burden. However, for patients, a poor preauthorization process means something worse: limited access to care. For healthcare professionals and administrators, understanding and implementing a structured prior authorization process is more than a compliance pretext; it is a route to ensure timely and quality care for patients.

This article investigates the impact of prior authorization delays on patient care and how you can improve the process to ensure better patient health outcomes.

Understanding Prior Authorization

It is a utilization management strategy by payers to control health expenditures and ensure quality of care. Providers must obtain approval from insurers before proceeding with specific treatments. The main purpose is to validate the medical necessity and cost efficiency of the prescribed medicine or procedures. Even though it started as a utilization management process, prior authorization often leads to delayed treatments considering administrative hurdles, prolonged approval periods, and communication gaps between payers and providers.

Impact of Poor Prior Authorization on Treatment Timelines

Prior authorizations are more than just a day-to-day challenge. The administrative burden associated with it chips away your time and profits. Let’s have a detailed look at the adverse impact of an inefficient prior authorization process on both providers and patients.

Administrative burden

Each procedure that requires preauthorization entails extensive and accurate paperwork. Additionally, follow-up phone calls and additional work for managing denials increase the administrative tasks for providers. In fact, a survey by the American Medical Association (AMA) has revealed that the average physician practice completes 43 prior authorization per week, with doctors and staff spending almost two business days a week completing the work. The varying demands imposed by different insurers are further worsening the condition.

Diverted time and resources

Authorization requirements for a single physician consume 12 hours of physician and staff time each week, and more than a third (35%) of physicians employ staff members to work exclusively on the prior authorization process. This results in reduced time for patient care which deteriorates the care quality. Also, it has been identified that 95% of the physicians reported that paperwork involved in the authorization process is significantly increasing physician burnout.

Worsening of medical condition

Interruptions in accessing necessary care escalate ailments, complicate their management, and escalate healthcare costs. Almost one in four doctors (24%) said that major adverse events, such as hospitalization, lasting damage, or death, have resulted from delays in obtaining authorization.

Psychological stress

The stress and unease linked to awaiting prior authorization approvals significantly impact a patient’s mental health. Neuroses like stress, depression, and anxiety are common among individuals handling long-term illnesses, and care delays exacerbate these conditions. Furthermore, individuals with mental health challenges may face heightened symptoms, reduced functionality, and increased crisis risks due to delays in obtaining prior authorization for crucial psychiatric treatments.

Potential Solutions to Prior Authorization

Streamline PA:

Enforcing a uniform authorization process with the help of electronic health record platforms can diminish the administrative burden and hasten the process. This can enable accurate data accumulation and swifter data transition among the stakeholders, reducing the chances of prior authorization denials.

Payer and provider collaboration:

Efficient communication among the providers and payers is crucial to understand the preauthorization requirements. Regular interactions, feedback loops, follow-ups, and aligned objectives can improve care delivery.

Patient advocacy and education:

Supporting individuals with information and their roles in the care process is important for better care. Educating your patients about insurance requirements and challenging denials can help reduce patient stress and frustration. You can consider demonstrating possible delays and tangible effects of the same on care, to prepare your patients for potential disruptions in treatment timelines.

The AMA is consistently advocating for the providers and patients considering the reformation of authorization rules and regulations. A collaborative approach among healthcare advocates and leaders can reduce the administrative burden on physicians while ensuring enhanced accessibility to high-quality care.

Balancing Cost Control and Patient Care

Managing prior authorization is a tough but critical part of healthcare. While the main goal of authorization is keeping the patients safe, improving health outcomes, and making care more affordable, the intricacies of the prior authorization process make it difficult for providers to keep pace with the changes. To lessen delays, you need a strategic approach to your practice’s authorization process. As the industry keeps changing, balancing cost control with quality care will always be a key challenge for everyone involved.

How Sun Knowledge Can Help

At Sun Knowledge Inc. we understand the critical aspects of prior authorization. As a leading prior authorization company, we offer an extensive range of services to healthcare providers in simplifying their revenue cycle management.

Our comprehensive prior authorization services are designed to –

• Reduce administrative burden
• Streamline the overall process
• Enhance patient satisfaction

Our curated prior authorization solutions comprise –

• Verification services
• Documentation services
• Initiating authorization requests
• Reauthorization
• Following up with the physician’s office
• Appealing denials, and more

For more than a decade we have been a top-tier pre-authorization service provider with extensive experience. By partnering with us you can have the benefits of –

• Affordable pricing
• 100% HIPAA compliance
• Maximized reimbursements
• Data security and robust PHI protection
• Quick turnaround time
• Reduced overhead costs

Want to learn more about our services? Reach out to our RCM experts at (646) 661-7853 today!