Prior authorizations play a crucial role in the revenue cycle. The process greatly impacts reimbursement and patient access to care, and consequently, the financial performance of healthcare organizations.  To simplify the process and reduce denials, a growing number of healthcare providers have pinned their hopes on prior authorization automation. 

The benefits of adopting prior authorization automation

Prior authorization automation shows promising results across the healthcare industry. Reporting on a recent survey, HealthLeaders notes that 78% of respondents saw improved financial performance following implementation of automated prior authorization. What contributes to better bottom lines? 

• Automation eliminates repetitive data entry, improving staff efficiency. This allows for operational savings because you can re-allocate staff to higher value tasks.
• By removing repetitive data entry, automation also helps reduce preventable denials resulting from typographical errors or missing information. 
• Because prior authorization software  pre-checks submissions for compliance with payer rules, turn-around time improves, enabling a smoother revenue flow, higher patient satisfaction, and improved health outcomes. 

Overcoming challenges in prior authorization automation

Despite the considerable benefits, the path to automation does present obstacles. Developing automated prior authorization in-house can quickly evolve into an expensive and time-consuming venture. 

Just maintaining an up-to-date record of evolving prior authorization requirements for 1000+ public and private payers demands considerable work. After all, you have to keep pace with more than 2.5 million prior authorization rules and prerequisites as they change. For example, prior to 2021, providers subscribed GLP-1 (Glucagon-Like Peptide-1) therapies primarily for the treatment of type 2 diabetes. After the U.S. Food & Drug Administration (FDA) approved the use of GLP-1 for chronic weight management, however, demand surged. As a result, FierceHealthcare reports that payer coverage for GLP-1 drugs has decreased by 50% since December 2022. That’s a lot of changes to absorb in order to keep automated prior authorization running smoothly. 

Overcoming these challenges requires a strategic approach. Consequently, choosing a technology partner can make or break your efforts. Conducting careful evaluations and comparisons of vendors, based on factors like their experience, customer support services, and product demonstrations can help you make an informed decision. What should you look for?  Recently, a Medical Economics article offered three qualifications to look for:

1. Use of Robotic Process Automation (RPA)—or bots—to handle routine tasks, like efficiently gathering information and navigating payer-specific portals. 
2. Tracking of payer regulations and maintaining an up-to-date payer policy library to ensure compliance and reduce denials or rejections that must be reworked.  
3. Transparency into prior authorization denials. The article notes, “Providing clear visibility into PA denials enables staff to identify and understand common reasons for denials, make necessary adjustments to their processes, and ensure accurate, complete submissions in the future.”

With the right partner, an inefficient prior authorization process gets displaced by an efficient, streamlined process integrated into your natural workflow. 

The future of prior authorization automation is now

Prior authorization automation presents a substantial opportunity for healthcare organizations to improve their financial performance. By harnessing the power of automation, providers can streamline the prior authorization process, reduce denials, and enhance the revenue cycle.

While the path to automation may have its challenges, careful planning and strategic decision-making can help you navigate these obstacles effectively.

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