- November 14, 2024
- Posted by: David Smith
- Category: Prior Authorization
In the dynamic healthcare sector, one aspect persists: prior authorization. This is a crucial step for aligning patient care with insurance protocols.
However, this extensive process often results in care delays and adds more administrative complexities within the practice management.
In fact, a survey by the American Medical Association in 2023 has identified that 94% of the providers agreed that prior authorization process induce care delays. 78% of the respondents said that there are cases of care abandonment due to the delays within the process.
Additionally, physicians have reported a higher level of administrative burden with prior authorization As per the survey practices on average complete 43 preauthorization per week and spend almost 15 hours on them, which is almost two business days.
Providers like you are always fighting with disruptions in patient care, dissatisfaction among patients and humongous paperwork.
What are the Reasons for Prior Authorization Delays?
Prior authorization was introduced as a measure of healthcare cost control and appropriate care for patients. However, with time, the complexities and paperwork have increased resulting in care delays and more administrative burden on providers.
There are several reasons for prior authorization denials, ranging from incomplete and incorrect documentation to non-compliance with payer policies. According to consensus, some of the reasons for PA denials are-
Inadequate information and documentation
- Lack of PA request
- Duplicate requests
- Administrative errors
- Plan coverage limits
- Lack of medical necessity
- Non-formulary medications
- Non-compliance with payer guidelines
- Pre-existing condition exclusion
Why Prior Authorizations are Hard to Manage?
The challenges around preauthorization would not be this troublesome without the high volume of requests.
In fact, while a survey by the AMA in 2021 shows that 62% of the providers are having trouble with this process, the 2023 survey showed a spike in the percentage, that is 94%!
A basic prior authorization request can take 30 to 45 minutes to complete and therefore taking away your valuable time for patient care resulting in poor quality of care and patient health outcomes.
For instance, if you are serving a patient with hypertension, you need to compile all the previous information, and past medications used by the patient, make multiple phone calls and complete the tedious paperwork. All the while your patient goes without the medication they need. The delays in the prior authorization process allow their blood pressure to remain out of control in the interim.
Another major reason for the complexities within the process is lack of collaboration among payers and providers. The business objectives, processes and workflows are not often aligned with each other resulting in communication gaps and misinterpretation of information. This further delays the approval and care process.
Read More:
Optimizing Prior Authorization: How to Handle Challenges and Boost Productivity
Struggling with prior authorisation? Optimising prior authorisation can reduce costs and delays. Explore effective strategies in our latest blog!
How to Minimize Prior Authorization Delays?
Healthcare leaders and providers are looking for effective ways through which they can minimize delays and denials in prior authorization. To better manage the burdensome process, you can consider the following strategies-
1) Check the prior authorization requirements:
If you develop a clear idea about the payers’ requirements in prior authorization appeal half of your problem is already solved. This will minimize the delays in filing prescriptions, denials or claims and lost payments that can be resulted from unmet authorization requirements.
2) Develop a PA protocol:
Following a uniform protocol regarding prior authorization appeal and workflow can help you mitigate the challenges in the process. Consider a dedicated team for information collection and authorization processing with a defined workflow.
3) Select the correct PA method:
A variety of prior authorization methods are available in the industry including standard electronic transactions, health plan portals, fax, telephone and so on. A prior authorization toolkit by the AMA elaborates on the advantages and disadvantages of each method. You can implement them as per your practice requirements.
4) Regular follow-up:
The preauthorization process is primarily manual. Therefore, it is quite common that there will be misplaced information or even requests. You need to track and monitor the status of the authorization and understand the requirements within the process.
5) Well-defined appeal process:
With the increasing complexities prior authorization denials will be more common within the industry adding to the existing burden of the healthcare providers. You can avoid this with a structured appeal process within your practice. You must make sure all required information is present in the resubmission to obtain prior authorization.
Conclusion
Of course, prior authorization is a cumbersome process adding layers of complexities in practice management and care process simultaneously.
Reports have suggested that prior authorization denials are more than 12% which indicates a substantial revenue loss and disrupted care process. In fact, practices are losing $5 billion annually across the industry. This is why optimizing your authorization process is essential for efficient revenue cycle management.
Outsourcing to a reputable prior authorization company like Sun Knowledge Inc, can be your answer to prior authorization dilemma.
As a leading prior authorization service provider, the company offers you an extensive range of services to simplify your practice’s financial nuances.
By partnering with them you will have the benefits of-
- Verification services
- Documentation services
- Hassle-free claim settlements
- Complex coding management
- Follow-up services
In these times of rising competition and changing patient and payer behavior, you should consider a strategic approach that can optimize your revenue in the long run.