Pre-authorization approval represents one of the most critical junctures in the healthcare journey for many patients. When authorization status is in question or long turnaround times are at play, it can delay patient care and negatively impact outcomes. Here’s how to create a better prior authorization workflow.
Prior authorization is approval from a health plan before a patient can obtain a medical service or fill a prescription for the service/prescription to be covered by a patient’s health plan.
The prior authorization process is sometimes given other names, such as prior auth, PA, preauthorization, precertification, prior approval, prior notification, prospective review, predetermination, or prior review. No matter what it’s called in healthcare, both medical and prescription prior authorizations can still be a giant headache for any practice.
Prior authorization also plays an important role in the revenue cycle. Before many services can be performed or prescriptions can be dispensed, providers must confirm whether approval is required and secure authorization from the patient’s health plan. Delays or errors at this stage can affect scheduling, reimbursement, and patient satisfaction.
Let’s say a patient’s health plan requires prior auth before approving an advanced imaging study. A provider must submit documentation demonstrating medical necessity before services can move forward and be eligible for coverage.
Oftentimes, a provider and patient won’t know prior authorization is required until the patient attempts to fill a prescription at their local pharmacy. Many pharmacists and patients wind up calling practices for prior auth that they likely won’t get immediately.
The American Medical Association (AMA) found that 91% of patients experience at least some delay in receiving care due to lengthy prior auth procedures. And according to an MGMA stat poll, one in three doctors have seen a prior auth issue lead to a serious adverse event.
In fact, 28% of physicians in an American Medical Association (AMA) survey said, “the prior authorization process required by health insurers for certain drugs, tests, and treatments has led to serious or life-threatening adverse events for patients.” It turns out that 16% of physicians reported that prior auth led to patient hospitalization because of the delay.
Getting the prior authorization process wrong means that procedures or testing could be delayed. The amount of time it takes to receive a prior auth ranges from a few hours to several days or more. The timeline you face will vary based on the payer and the type of service you are seeking approval for. These delays can be especially difficult when you are serving patients who are enrolled in Medicare Advantage or Medicaid plans.
Submitting a prior authorization can be time-intensive with no shortage of miscommunications. Pharmacists or doctors may forget or neglect to start the requests, fax machines may malfunction, or phone conversations with an insurance provider may not result the way you’d like.
A recent AMA survey found that practices complete 40 prior authorization requests per physician per week. Processing these requests takes approximately 16 hours per week, so it comes as no surprise that 85% of physicians described prior authorization as a high or extremely high burden.
Sadly, that burden is only getting worse. Eighty-four percent of providers say the number of medical services that require prior auth has increased, according to a survey by WEDI, a nonprofit organization that studies the use of health IT to create efficiencies in healthcare information exchange.
Not only has the number of services that require prior authorization increased, but 90% of healthcare leaders reported that prior auth requirements have also increased, according to an MGMA stat poll.
When documents are incomplete or a staff member misses authorization requirements, it creates significant rework. Staff may need to revisit patient records, obtain additional clinical information, or appeal a denied claim before care can proceed.
It turns out that 62% of providers feel they do not have the technology to evaluate whether a prior authorization is required for a medical service, diagnostic test, or medication without initiating a prior authorization request, per the WEDI survey.
Providers cite their phones as the most commonly used method for completing PAs. Only 24% of physicians report that their EHR system offers electronic prior authorizations for prescription medications.
Electronic prior authorization (ePA) is an automated prior authorization solution that can save a practice hours and even days of work and is available with most EHRs. With this solution readily available, the patient can leave the office with a valid prescription, improving patient care.
Providers can use modern ePA solutions to initiate requests electronically, attach supporting documentation, and monitor authorization status in real time. The best tools will integrate with your eligibility verification and insurance information systems so that staff can identify what’s required for prior authorization. That way, they can send the right information the first time and reduce the risk of delays.
Even though ePA would potentially save providers $355 million annually from a complete shift to electronic PA processes, according to the Council for Affordable Quality Healthcare (CAQH) report, medical plans were slow to adopt electronic prior authorization as compared to other administrative transactions in 2019. That being said, sending prior authorization requests electronically through payer portals has increased in popularity.
Anders Gilberg, senior vice president of the Medical Group Management Association (MGMA), said in a written statement:
“Practices should not be forced to rely on fax machines to complete manual prior authorizations when health plans could modernize the process.” He continued, “The federal government needs to streamline prior authorization by requiring a national automated approach to minimize administrative costs and delays in patient care.”
The Fast Prior Authorization Technology Highway initiative aims to utilize technology from Availity and Surescripts to speed up requests and responses for prior authorization requests. This initiative is captained by the insurance industry group America’s Health Insurance Plans and several insurers, including Anthem, Cigna, and WellCare. Part of this initiative involves volunteers working with insurers to incorporate new processes into existing technology.
Creating a better prior authorization workflow is a team effort. Connect with payer groups and policymakers to identify ways you can reduce administrative friction. When providers and payers work together more seamlessly, it benefits everyone, especially patients.
Getting rid of duplicate requests can also reduce bottlenecks. When payers don’t have to spend time cleaning up errors or kicking back requests, they can devote more resources to reviewing legitimate prior auth files.
Healthcare organizations can create a better prior authorization workflow by upgrading their revenue cycle technologies. Solutions that assist with important transactions will promote efficiency and reduce manual effort.
Those eight transactions are:
Organizations should also track KPIs related to authorization management, including approval rates and turnaround times. These data points can help you identify bottlenecks and opportunities for process improvement.
Here’s how to create a better prior authorization workflow through improved collaboration:
Multiple entities are involved in the prior authorization workflow. Make sure that each person involved in the process knows what their roles are and where to relay information. That way, you can reduce the risk of requests being delayed or overlooked. Scheduling and registration teams can identify prior auth requirements early, while billing personnel can monitor the status of these authorization requests.
Authorization requests will get kicked back if the request is missing important documents. Identify what payers require for different types of prior auth requests and create a checklist for your team to follow.
Standardizing the documentation process will help providers consistently include the information that payers require. The more complete the initial submissions, the lower the odds of rework.
Prior authorization requirements change frequently, and payer rules can vary between health plans. Educating your team members will help keep everyone familiar with the latest requirements and workflow expectations. Your organization should maintain up-to-date process documentation and share payer policy updates across the entire workforce.
Prior authorization workflows can break down when departments operate in silos. Regular communication between your clinical, administrative, and billing teams will help identify bottlenecks so you can create more efficient workflows.
Routinely examine your workflows to look at denial trends, approval timelines, and recurring documentation issues. These discussions create opportunities for continuous process improvement while helping your team respond effectively to changing payer requirements.
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To improve your prior authorization workflow, you need to:
How long is it taking you to receive a prior authorization, on average? How does this average fluctuate between different procedures and payers? Every healthcare system needs to know the answers to these questions.
Monitoring your turnaround times will help you identify where delays are occurring and why. Improving your turnaround times can promote more efficient scheduling and reduce care delays. The end result is a better patient experience.
Every time one of your team members has to rework or resubmit an authorization request, it increases their administrative workload. Track your rework rates so you can understand how often these challenges are occurring. High rework is a red flag that there are issues in your processes or documentation.
Many healthcare organizations spend a significant amount of time checking authorization status and contacting payers for follow-up. Measuring your follow-up activities can reveal how much effort is being spent managing pending authorizations. Automation tools can reduce this burden while providing greater visibility into the status of prior auth requests.
Analyze how your revenue cycle is performing and how prior auth may be impacting your bottom line. If you get better at obtaining prior authorizations, it will have positive downstream effects on your revenue.
If you oversee a multi-provider practice or large health system, it’s important to evaluate authorization performance holistically and at the department or location level. Compare metrics across different teams to identify best practices and standardize successful workflows.
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Managing the prior authorization workflow effectively is essential for healthcare providers to reduce delays, improve patient care, and alleviate the administrative burden on staff. Below are actionable strategies to streamline the prior authorization process and enhance efficiency in your practice:
Adopting electronic prior authorization (ePA) tools can significantly reduce the time and effort required for prior authorization requests. These tools, often integrated with EHR systems, automate key steps, enabling providers to submit requests directly to payers, track their status in real-time, and receive faster responses.
Creating a standardized prior authorization workflow ensures consistency and minimizes errors. Assign specific roles for staff to handle tasks such as verifying medical necessity, checking insurance plan requirements, and following up on pending authorizations.
Verify insurance eligibility and prior authorization requirements upfront before scheduling treatments or services. Automated tools can flag cases needing pre-authorization, reducing instances of denied claims due to incomplete or missing approvals.
Educating staff about payer-specific requirements, such as documentation for medical services or prescription drugs, helps prevent delays caused by incomplete submissions. Regular updates on prior authorization requirements ensure compliance with evolving payer policies.
Tracking key metrics like average approval time, rejection rates, and the volume of prior authorization requests helps identify bottlenecks in your workflow. Use this data to refine processes and allocate resources where they are most needed.
Establishing strong communication with insurance companies and payers can facilitate quicker approvals. Advocate for clearer guidelines and transparency in pre-authorization requirements to minimize inefficiencies.
By integrating ePA solutions, automating processes, and fostering collaboration with payers, healthcare practices can reduce the administrative burden, improve patient access to timely care, and optimize their overall workflow.
Rivet is a reimbursement software that gives you the big picture of what’s going on in your practice with payer contracts, fee schedules, and claim payment discrepancies such as denials and underpayments. You can also check eligibility and provide accurate up-front patient cost estimates before services are rendered. The Rivet team will help you aggregate your fee schedules and input your claims data to enable you to increase revenue and decrease A/R days.
For more information about the tools Rivet provides, schedule a Rivet demo.
A prior authorization workflow refers to the series of steps healthcare providers follow to obtain approval from health insurance companies before providing certain medical services or prescriptions to ensure reimbursement.
Prior authorization helps ensure that prescribed treatments, tests, or medications are covered under a patient’s insurance plan and deemed medically necessary. It prevents unexpected costs for patients and aligns with payer requirements.
ePA automates the submission, tracking, and approval process for prior authorizations, reducing manual tasks, minimizing delays, and improving the efficiency of healthcare workflows.
Challenges include time-intensive manual processes, incomplete documentation, varying payer requirements, and frequent delays in approvals, all of which contribute to an increased administrative burden on providers.
Providers can reduce delays by implementing ePA solutions, standardizing workflows, training staff on payer requirements, and using automated tools for eligibility verification.
No, prior authorization requirements vary by payer, health plan, and service type. It’s essential for providers to stay updated on the specific guidelines of each insurance company they work with.
Delays in obtaining prior authorization can postpone treatment and negatively impact patient care. Streamlining workflows and using automated tools can help ensure timely access to necessary treatments.
While automation significantly reduces manual tasks, some aspects, like additional documentation or medical necessity reviews, may still require human intervention. However, automation drastically improves efficiency.
The American Medical Association (AMA) advocates for reducing the administrative burden of prior authorizations and promotes the adoption of electronic prior authorization to improve efficiency and patient outcomes.
Providers should stay informed about changes in payer policies, invest in scalable ePA solutions, and regularly update workflows to adapt to evolving prior authorization requirements.
