The Far-Reaching Impact of Prior Authorization You Didn’t Know About

The Prior Authorization process is one of the most intricate and resource-intensive tasks faced by healthcare providers today. It has been a pervasive issue in the industry for years and has brought many to the debate indicating its efficiency and disadvantages.

The complexity of Prior Authorization (PA) is not just an administrative issue. It has real

consequences on patient care, owing to its notorious propensity to cause delays in treatment. With the advent of the digital era, there are many options available now to explore and implement that effectively reduce many of the challenges associated with preauthorization. However, as a provider, you must look for a holistic approach and understand the nuances of PA to execute the same properly. This is necessary to create a truly consummate healthcare practice and ensure the best outcome for all the parties involved – providers, payers and patients.

The Cross-Industry Impact of Prior Authorization Process

1. Providers: Though the Prior Authorization process lies in the hands of payers, as a provider you know the difficulties and frustration of the process. The time, energy, and cost required for preauthorization is a matter of concern for physicians across the country. Due to lengthy approval times, scheduling a patient’s treatment or procedures can be delayed. This frustrates the patients and can result in adverse events. On the other hand, frequent PA denials result in increased administrative burden, increased operating costs, and care delays. Furthermore, as an independent provider or as a larger healthcare facility, you must deal with different payers and their PA submission guidelines. This further adds to the stress and frustration, often leading to burnout.
2. Payers: Within the payer PA process, a highly skilled workforce including physicians and nurses is utilized. It has been identified that review processes are not straightforward as they require a thorough review of each case. Also, the mandated timelines for PA submission and review increase the burden on the payer’s staff as well. Additional provider follow-ups and a lack of staff for the review process increase difficulties for payers too.
3. Patients: Ultimately, the patients suffer the most from the preauthorization process. Delays in treatment are frustrating and may increase existing illness. This administrative barrier to the care process may result in the patient abandoning their treatment, thus resulting in undesirable health outcomes.

The Complexities of Prior Authorization

Healthcare organizations are in a tough spot between the increasing complexity of the PA process and the consistent skill shortage in the industry. The major challenges within the Prior Authorization process are:

1. Manually intensive process: You must complete a series of steps to receive Prior Authorization. The majority of these take place outside of the core electronic health record workflow. Furthermore, the somewhat antiquated and paper-based task of PA requires proper and detailed documentation, without which there are strong chances of denial.
2. Ever-changing payer rules: PA rules vary from payer to payer, and frequent rule updates result in increased staff confusion. Healthcare practices find it challenging to stay ahead of the requirements to get their prior authorization requests accepted, which prolongs the time it takes for an auth to be completed and also increases the frequency of denials. This is a practical problem that most providers face, and the shifting laws and the general complexity of payer reimbursement are to be blamed.
3. Lack of transparency: Along with frequent changes within the rules, the lack of transparency in PA rules from the payer’s end is a major concern for the providers. For instance, by entering the procedure’s CPT code, certain payer portals make it simple to find the necessary auth information. It takes longer for everyone when you contact other payers to find out the requirements because they would not tell you until you verify the patient benefits.
4. Limited electronic adoption: According to the Council for Affordable Quality Healthcare Index report 2023, Prior Authorization holds the lowest electronic adoption rate at 31%. Though it has increased compared to the adoption rate in 2021, the tedious and manual nature of the process continues to persist, increasing the complexity within PA.

Making Prior Authorization a Better Experience

With an impressive track record of helping medical practitioners and healthcare facilities of all sizes across the country, Sunknowledge Services Inc. is your one-stop destination for full support with Prior Authorization. Navigating through the PA challenges efficiently is essential to amplify your practice management efforts. By partnering with us you can improve your PA experience.

Only at Sunknowledge, you will have the benefits of:

• 80% savings on overhead costs
• 99.9% accuracy rate overall
• Up to 97% collection rate
• Customized reporting tailored to the protocol of the client
• Keeping a regular eye on changes and developments in the PA marketplace
• Regular follow-ups to close the communication gap with the insurance team

We assure you of consistent quality management within your practice by navigating your preauthorization challenges with accuracy, expertise and confidence. To learn more about our processes, you can connect with one of our experts over a non-commitment call today!