- February 11, 2025
- Posted by: Josh Knoll
- Category: Prior Authorization
Prior authorization (also known as pre-authorization or pre-certification) is a distinctive feature of the healthcare system in the US. Essentially a mandate implemented by insurance companies, or Payers, prior authorization is a ‘utilization management’ measure, designed to curb healthcare expenses, control unnecessary spending, and also ensure a better, and safer, outcome for the patient.
In spite of their noble intentions, prior auths suffer from a peculiar duality of reputation.
Let me explain.
While this all-important regulatory requirement is considered to be an effective means for making treatments more efficient and prevent unnecessary spending, it is also infamous for eating too much into a healthcare practice’s time and for causing delays, often with disastrous results.
The American Medical Association’s prior authorization (PA) physician survey, published in February, 2023, found that “medical practices complete about 45 PAs per physician per week, spending almost two business days (14 hours) every week.”
Prior Authorization: A Necessary Evil?
Everything mentioned above leads to a moot question – is prior authorization good or bad?
Does it really help in making things better, or is it an impediment in the path of ensuring improved patient outcome?
The question is not easy to answer. Even as voices continue to rise against abolishing prior authorization, or make the whole process uniform, quicker and simpler, it shows little sign of abatement. One can however be sure about one thing. Prior auths are not going away anytime soon.
This is an important realization for all providers, especially those who have to get their services authorized on a regular and frequent basis. Securing authorization on time is crucial for ensuring eventual coverage by the Payer, avoiding unpleasant surprises afterwards, reducing chances of setbacks during collection, and making sure that no revenue falls through the cracks.
Efficient prior authorization services also have a beneficial effect on patient satisfaction. An authorization request – initiated, followed through, and completed in time – means that the patient can get started with their treatment plan without delays. There is less abandonment too.
Top Challenges of Prior Authorization
Studies with providers have shown that prior authorization is associated with some distinct challenges. In 80% cases, the chief challenge is perceived as resulting from inconsistent insurer payment policies while 88% cases pointed at delays in care.
In the most number of cases (92%), the greatest challenge was seen as the need to hire/redistribute additional staff to work on prior authorizations due to increased volumes.
Authorization requirements for routinely approved items were also complained about in 83% of cases.
As one continues to delve deeper into the matter and continue thinking about possible solutions, it becomes evident that the right answer to all of the challenges above is in having specialized knowledge and the necessary skill-set to tackle prior authorizations with precision, accuracy, and confidence.
This explains the growing need for specialized prior authorization services as might be provided by an experienced prior authorization company. For innumerable healthcare providers across the country, prior authorization outsourcing has become a crucial buzzword.
Let’s take a closer view.
In Search of Professional Prior Authorization Solutions
The rise in minimum wages for healthcare workers (especially administrative and non-clinical staff) in many parts of the country, coupled with a general scarcity of skilled workers, have jointly contributed to increasing difficulties in sustainable and convenient recruitment. In recent years, especially in the post-COVID era, onshore recruitment has become extremely challenging and expensive.
Yet, the truth is, any healthcare organization worth its salt needs skilled and trained people to manage its billing and administrative affairs.
In view of such state of affairs, offshore prior authorization outsourcing is fast becoming the strategic business maneuver of choice for countless physicians and healthcare practices looking to effectively streamline their prior auth operations without breaking the bank, or having to sweat over conventional recruitment bottlenecks.
Finding the Perfect Prior Authorization Company
Locating an offshore prior authorization company is not a difficult proposition these days. Identifying the right one for you, is.
Every healthcare business has varying requirements regarding prior authorization. The nature of the specialty, the kinds of insurances that it accepts (Private, Medicare, or Medicaid), the general volume of PA requests that it needs to deal with daily, the skill of existing staff members handling such requests – they all determine the kind of assistance that could help make things better.
The hunt for the provider of the best prior authorization solutions, therefore, should begin with some introspection. A preliminary discussion with a prospective partner can be very helpful in this regard. It can help reveal the real challenges that a particular practice is facing with regard to pre-certification. This mutual understanding can pave the way for the perfect partnership where the party seeking help is matched with the perfect set of solutions to meet his needs.
Further Thoughts on Picking the Best Prior Auth Partner
Another concern to bear in mind while trying to outsource prior authorization is carefully evaluating all the usual aspects of any prospective managerial partnership, such as experience, expertise, credentials & certification, testimonials from clients, transparency of operations, accessibility and, of course, the pricing.
These are important questions to ask, and get answers to, before selecting an offshore partner to whom you would entrust your prior authorization. In spite of the growing proliferation of online prior authorization (or e-Authorization, as it is commonly referred to), many payers still accept paper-based documentation and traditional faxes. It is, therefore, a wiser decision to choose a company that is well-versed in both these methods.
Preparing to Solve the Prior Authorization Jigsaw
Companies dealing in RCM (Revenue Cycle Management) for healthcare providers often shy away from taking on prior authorization tasks. The hassles are too many, and the complexity is too much. It takes a true and confident expert to do justice to the stringent demands of the job, such as Sunknowledge Inc.
For close to 18 years, Sunknowledge has been at the leading front of providing top-notch support in pre-authorization to providers in over 30 specialties. Contact us to schedule a discovery call and get a tailored plan for your practice.