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May 12, 2022

Get the FAQs about Automated Prior Authorization

by Susan Lawson-Dawson | Prior Authorization

Healthcare providers operate with razor-thin margins. Where can you shave down expenses? Increasingly, all eyes are on automated prior authorization. 

Prior authorization has been flagged as one of the most costly and time-consuming administrative processes in healthcare, and the burden keeps growing. With 4 out of 5 healthcare providers reporting that prior authorization requirements continued to increase in the past year, a more streamlined, automated process is certainly appealing. 

Want to know more about automated prior authorization before you make the leap? Check out these FAQs to learn more. 

What’s the difference between prior authorization (PA), electronic prior authorization (ePA) and automated PA? 

Currently, healthcare providers rely on a mostly manual process for determining if PA is required, identifying and gathering requisite information, submitting documentation, and following up on determinations. Reliance on repetitive data entry, phone calls and faxes is only part of the problem. PA specialists also spend an excessive amount of time on detective work, tracking down patient benefit details, clinical documentation and PA criteria scattered across different locations with little connectivity to speed the process. 

Similarly, ePA uses a manual process up to the point of submission, when the PA request is submitted via a payer’s web portal or EDI 278 transaction. Automated PA represents a narrow subset of ePAs. 

Automated PA takes advantage of technology and aggregated patient, provider and payer data—what we call Collective Healthcare Intelligence™—to accelerate the process. Rather than manual data entry and frustrating hold times on the phone, automated PA requires minimal input, automatically piping in the required patient, provider, and encounter details directly from the EMR or other system of record once a prior authorization is determined to be required. Once a PA submission is prepared, it is automatically submitted via the specific payer’s preferred channel, whether a payer web portal or electronic fax.  

Why should I make the shift to automated PA? 

As prior authorizations requirements continue to expand, manually managing prior authorizations just gets harder—especially in the midst of a staffing shortage. Submission volume is only one part of the challenge. The number of insurance planseach with its own forms and policies, third-party portals, and PA processes—adds a layer of complexity. The status quo simply can’t keep up with these challenges and it prolongs patient care. 

  • 93% of HCPs report care delays due to PA
  • 34% say such delays have led to a serious adverse event for a patient 

Automated PA expedites the process and reduces potential for typos, missing information and subsequent rework if errors lead to a denial. More importantly, the improved speed and accuracy of a digital process alleviates the risk of unnecessary treatment delays or abandonment.

Who benefits from automated PA? 

Providers

Analysis of a Midwestern integrated health system found the costs of manually managing prior authorizations in 2019 exceeded $18 million, including $3.6 million in lost revenue as a result of PA delays that led to cancellations or rescheduling of procedures.  

A more efficient, cost-effective approach is just what the doctor ordered—and it’s not just large health systems that can realize significant benefits from a more connected, technology-driven process. Physician practices, diagnostic labs, out-patient or in-home infusion therapy services, pharmacies, and more can realize measurable time and cost savings. If all providers implemented automated PA, CAQH estimates the annual cost savings within the medical industry would be $437 million. 

Payers

Payers gain similar time and cost savings because of more efficient, accurate throughput of PA submissions. With all requests in one place and improved systems interoperability, payers can make fast, clinically-supported decisions to ensure members receive timely, appropriate care. 

Data-driven auto-adjudication speeds the process further, allowing payers to batch approve PA requests based on historical accuracy of previous submissions. 

Patients

Ultimately, it’s your patients that matter most. Automated PA can eliminate the bottlenecks in their care journey, ensuring they have access to care when they need it most. And that means improved patient experiences that reflect well on your organization. 

Want to see automated PA in action? 

Connect with Myndshft to arrange a demo.