Prior authorization has long been a source of frustration for providers. The administrative headaches can turn your workflow into a chaotic mess. What’s more, the resulting delays and treatment abandonment arising from an inefficient prior authorization process negatively impacts your patients’ health outcomes. Not to mention how it affects your revenue cycle. Prior authorization software transforms chaos into calm, making your workflow smoother and more efficient than ever before. 

Administrative burdens contribute to clinician and staff burnout 

COVID-19 no longer qualifies as a global emergency, but clinician and staff burnout remains high. A 2023 report on physician burnout, for example, found that the burnout rate rose from 47% in 2021 to 53% in 2022. Why are the numbers still rising when the demands of the pandemic have fallen? According to that report, 61% of physicians point to “having too many bureaucratic tests” as the biggest contributor to burnout. ​​ And let’s face it: Prior authorization earns top billing as an administrative hassle. 

In fact, earlier this year, U.S. Surgeon General Vivek Murthy, M.D. emphasized the need to eliminate bureaucratic barriers to reduce burnout. Fierce Healthcare reports that during an AMA webinar, Murthy told out-going AMA President Jack Resneck Jr., M.D. that, “To be denied the care, often time-sensitive care, that a patient needs because of a bureaucratic process that often feels like it’s set up to inhibit care and prevent expenditures rather than improve quality of care—that hurts patients and doctors.” He added, “It’s incredibly difficult not to lose faith in the system.”  

And it’s not just clinicians feeling the strain from prior authorization paperwork.  Overburdened front and back office staff get bogged down by an inefficient process that relies heavily on repetitive manual data entry. According to the MGMA Regulatory Burden Report, 89% of providers say they have hired or redistributed staff to work on prior authorizations due to increasing volume. 

Here are the typical steps in the workflow for prior authorization:

Determine if Prior Authorization is Necessary

Not all services or medications require prior authorization. First you need to verify a patient’s benefits and determine if the desired procedure, service, or medication requires prior authorization based on the payer’s policies. Unfortunately, this means digging through payer documentation online or in a payer “Bible” maintained by your staff. And if you can’t find the details in those places, you have to follow up with phone calls (and hold time) with payers. 

Gather Relevant Information

After determining if prior authorization is necessary, you need to collect all relevant information needed for the request. This might include details from the patient’s medical history, information about the proposed procedure, service, or medication, the reason why it is necessary, and any supporting documentation, such as results from lab work or imaging.  Unfortunately, prior authorization policies differ from payer to payer. This lack of consistency adds to the administrative challenges. 

Submit Request to the Payer 

The healthcare provider, often a nurse or administrative professional, completes the prior authorization request form provided by the payer. This form, along with the necessary documentation, is sent to the payer. Even this poses a challenge. Some payers accept electronic submissions; others prefer faxes, so with a manual process you need to know which submission path to take—or do more legwork to find out. 

Insurance Review

The payer reviews the request. This may involve a medical director or nurse reviewing the information provided and comparing it against coverage policies and guidelines. Another catch-22:  Sending too much information when submitting a prior authorization can garner a denial just as easily as sending too little. 

Decision Notification

After reviewing the prior authorization request, the payer will then notify you of the decision. What if you don’t hear back right away? That’s par for the course, which means your staff continues to spend time tracking the status of a submission.  If the request is approved, then you can move ahead and provide the service or medication to the patient. If the request is denied, you may rework the request based on feedback from the payer. You may also appeal the decision. 

Appeal Process (if necessary) 

If the prior authorization request is denied, you and your patient have the right to appeal the decision. This involves submitting additional documentation or clarification on why the service or medication is medically necessary. The payer will then review the appeal and make a new decision. Kaiser Family Foundation (KFF) analysis of Medicare Advantage prior authorizations in 2021, for example, found that 82% of appeals led to “fully or partially overturning the initial prior authorization denial.”  Talk about frustrating!   Preventable denials add to your workload and slow patients’ access to medically-necessary care. 

Tame the paper tiger with prior auth software

By comparison, using prior authorization software streamlines the process. The entire manual process—from benefits verification to prior authorization submission and status monitoring—averages 48 minutes per prior auth. With fully-automated, end-to-end prior authorization software, the process shrinks down to less than 6 minutes. (Bonus: You don’t have to listen to mind-numbing hold music waiting for payers to pick up the phone.) 

Imagine a world where repetitive tasks are handled effortlessly, freeing up your time for more important matters. It’s already here. With prior authorization software, you enter minimal data to get the ball rolling. 

The software uses intelligent automation and seamless connections to what we call Collective Healthcare Intelligence™—patients’ health and benefits information, providers’ clinical documentation, and payers’ plans and policies—to quickly pull the appropriate information, automatically populate the payer’s form, and send it with relevant attachments via the payer’s preferred submission method. You can let the software do the heavy lifting while you concentrate on delivering quality healthcare.

Prior authorization software facilitates improved collaboration among different stakeholders involved in the process, from providers to pharmacists to payers. It reduces preventable errors, eliminating miscommunication and fostering a faster flow of information. Collaboration becomes a breeze, and chaos becomes a distant memory. This is particularly important as we continue the journey toward value-based care. 

At the heart of it all, your primary focus is providing the best possible care to your patients. By reducing administrative burdens and streamlining workflows, you can dedicate more time and energy to patient interactions. Prior authorization software wrangles the chaos, brings tranquility to your workflow and more fluid care experiences to your patients. 

Say goodbye to paperwork nightmares and endless care delays.  Connect with Myndshft to get started.