Prior Authorization Software Cuts Time, Yet Faces Remaining Challenges

New England Baptist Hospital is contending with a significant issue prevalent in today’s healthcare landscape: insurance companies mandating prior authorizations for services prescribed by physicians. Complying with payer demands consumes valuable time, leads to treatment delays, and can impose substantial financial burdens on medical practices.

To address this challenge, New England Baptist Hospital, a prominent orthopedic facility in Boston, has implemented an automated system for submitting prior authorization requests. This initiative encompasses over 100 primarily orthopedic surgeons who are affiliated with the hospital. Through this automated process, the hospital aims to streamline the authorization workflow, mitigating the time-intensive burden placed on healthcare practitioners. By leveraging automation technology, the hospital seeks to expedite the authorization process, thereby minimizing treatment delays and optimizing operational efficiency.

“After utilizing this system for five years, we can confidently affirm that automation is highly effective,” stated Lidiya Hadzhieva, the hospital’s Director of Patient Access. She noted that the software has led to a 30% reduction in write-offs and a 25% decrease in staff costs. Hadzhieva also highlighted that prior authorizations are now approved within three days of scheduling, compared to the previous timeline of 11 days.

She added, “In addition to saving staff time, this software enhances the accuracy of predicting when prior authorization is required.”

For practices inundated with mandatory prior authorizations from insurers, automation is increasingly viewed as a means to streamline the process and achieve cost savings. Nonetheless, while software automation offers potential benefits, it can also incur significant costs and may not be feasible for many practices. Furthermore, a considerable number of physicians may not be aware of its existence.

Currently, the software is primarily implemented within large organizations such as hospital systems. However, as awareness spreads and the software’s usability improves, there is potential for private practices and smaller entities to embrace the automation trend.

Automating prior authorization is unquestionably imperative. According to the American Medical Association (AMA), physicians dedicate an average of 16 hours per week to prior authorizations. A recent AMA survey revealed that over 60% of physicians find it challenging to determine when prior authorization is necessary. Additionally, the AMA reported that 93% of physicians experience care delays while awaiting authorization.

Experts suggest that approximately 80% of prior authorization tasks could be automated, yet the majority of practices still rely on phone calls or fax machines for these processes. This trend persists despite a continual rise in the number of prior authorization requests.

How It Operates

Automation software establishes a direct connection to the practice’s electronic health record (EHR). “Once the doctor initiates an order in the EHR, the process begins automatically,” Hadzhieva explained. “The doctor might not even be aware of it.”

Moreover, aside from utilizing an EHR connection, numerous software solutions can interact with the payer via its portal or through fax or phone, all while automating various other aspects of the process.