Late last year, Fierce Healthcare noted that “…nearly a third of healthcare resources are tied up in administrative costs, taking focus away from patient care.”  The research, published by Health Affairs in 2018, reveals that billing complexity remains a source of payer-provider abrasion that must be addressed. If you want to uncomplicate the path to timely patient care, prior authorization software can help. 

3 Factors that Contribute to Physician and Member Abrasion

Dealing with healthcare payers—whether as a provider or a member—often results in frustration. What are the biggest hurdles to more satisfying (or at least, less irritating) experiences? 

Complex prior authorization requirements

The prior authorization process can be lengthy and complex, requiring significant time and resources to complete. There are more than 1,000 healthcare payers in the U.S.—each with their own plans and requirements. As a result, providers must navigate a  complicated web of rules and regulations to obtain prior authorization approval for their patients. 

How prior authorization software helps: Software removes the complexity by automating some of the most time-consuming aspects of the process. 

For example, with manual prior authorization, your staff needs to determine if prior authorization is needed, identify each individual payer’s rules and submission requirements, and populate the requested information. It’s a painstaking process, often relying on duplicate data entry and a scavenger hunt for payer details. 

With prior authorization software, your staff enters minimal information to get the ball rolling. Then the automation begins, pulling relevant information—what we call Collective Healthcare Intelligence™—covering patients’ health and benefits information, payers’ plans and policies and providers’ clinical documentation. 

The result? You experience a productivity boost, freeing staff and physicians to focus on patients, not paperwork. Since patients’ provider experiences influence how they feel about their insurance coverage, a smoother path to care improves their outlook as members. 

Lack of transparency

Ask any provider or member: Transparency isn’t exactly a hallmark of payers.  Unraveling each payers’ requirements takes time, creating a burden for both office staff and clinicians. Physicians may not have a clear understanding of documentation needed to support claims or criteria used to approve prior authorization requests. 

This lack of transparency can lead to abrasion and mistrust between physicians and payers. In addition, when your members experience hiccups in access to services, procedures or medications due to a delayed prior authorization, satisfaction with their insurance coverage declines. 

How prior authorization software helps: It uses exact payer policies and rules combined with automation to provide the clarity providers need to efficiently process prior authorizations. No more searching payer portals, spreadsheets, or paper binders looking for information. No more uncertainty about submission criteria. Instead, you can move from benefits verification through prior authorization submission in less than 7 minutes. It’s a huge time-saver compared to the CAQH estimate of 37 minutes or more for a manual end-to-end process (which doesn’t even include hold times when you resort to calling payers for information.) 

Delayed or denied payments

Physicians and members also experience frustration and abrasion when they encounter payment delays or denials. These issues can lead to cash flow problems for physicians and their practices. In turn, this affects their ability to provide quality care to their patients. In addition, delays and denials contribute to a poor member experience—especially if they wind up receiving a surprise bill. 

How prior authorization software helps: Automation streamlines the process, identifying the data required for a prior authorization submission, populating the appropriate form and submitting a prior authorization request via the providers’ preferred submission method.  

For example, automated prior authorization reduces the likelihood of typos from repetitive data entry, pulling in the right data from the right places to help ensure a clean submission. Myndshft users have reported up to 90% reduction in submission rework due to incorrect or missing information. Cleaner claims equal fewer delays and denials, which is better for patients and your bottom line. 

The Benefits Extend to All Stakeholders

Payers benefit from a streamlined process too. After all, any back-and-forth on prior authorization requests mean payers spend more time per prior authorization too. 

The Health Affairs study’s authors explain,  “When billing complexity declines, both physicians and patients stand to benefit. Time that physicians don’t spend on administration opens up opportunities to treat more patients or extend the length of visits, ultimately increasing the productivity of physician care.” The authors further note that “Easier billing processes reduce staffing needs and billing expenses, which could raise physicians’ incomes or free up resources for patient care. Savings that accrued to insurers could be used to reduce premiums.”  

Ultimately, prior authorization software improves experiences across the board. Less physician abrasion plus higher member satisfaction puts payers in a better position too. And with tools like clinical decision support and data-driven auto-adjudication on the payer side of prior authorization software, payers realize efficiencies and communication improvements that create stronger, positive relationships between the providers they work with and the members they serve. 

Want to see how prior authorization software works for yourself? Arrange a demo today.