Less CYA, More Efficiency: Prior Authorization Software’s Game-Changing Approach
No industry escapes administrative spending, but the healthcare industry encounters more than its fair share. Writing in Forbes, Bipartisan Policy Center Senior Fellow and Former Senate Majority Leader Bill Frist notes, “Estimates attribute 15 – 30 percent of total national health spending to administration, with at least half of that spending demonstrated to be ineffective or wasteful. That means as much as $300 – $600 billion is wasted each year.” Tackling inefficiencies in your processes—like over-processing prior authorization submissions—can certainly cut down on waste. That’s where prior authorization software can help. But first, let’s look at why it happens.
A CYA mindset bogs down prior authorizations
The CYA mindset has its roots in the fear of potential negative repercussions. Healthcare providers feel it even more keenly because their patients’ lives are on the line. As a result, they often feel compelled to submit exhaustive documentation, but that instinct can create its own problems.
Myndshft Chief Product Officer Tyler Wince explains, “Providers tend to overshare information on prior authorization requests because of uncertainty around payer requirements. This can lead to unnecessary submissions for services that don’t require prior authorization. In addition, it slows processing for valid prior authorization requests because the payer must sift through the provided data to find the information needed.”
Pitfalls of information overload with prior authorization submissions
As tempting as it is to include information just in case it’s needed, over-processing prior authorization submissions has several downsides.
- Increased workload: Providers already point to prior authorizations as a source of administrative burden with 88% of physicians describing it as ‘high’ or ‘extremely high’ according to the AMA’s 2022 Prior Authorization Survey. And with staffing challenges still in play, excessive paperwork and documentation from a CYA-driven prior authorization process only increases the workload.
- Delays in processing: Submitting excessive or irrelevant information can result in longer wait times for approvals, leaving patients in limbo.
- Increased likelihood of denial: Submitting excessive or irrelevant information can actually increase the likelihood of a PA request being denied. This is because the payer may have difficulty identifying the pertinent information needed to approve the request. When that happens, you could have a preventable denial on your hands and time-consuming rework to submit a revised prior authorization request.
- Higher administrative costs: Productivity takes a hit when prior authorization requests are over processed, and not just for providers. Excessive documentation on prior authorization requests takes longer to review from the payer perspective. As a result, administrative costs climb for both healthcare providers and payers, ultimately impacting the overall cost of healthcare.
- Frustration and potentially poorer health outcomes: Over-processing prior authorizations leads to frustration and confusion for all parties involved. The impact hits patients hardest, as 33% of physicians report that prior authorization delays have led to a serious adverse event for a patient in their care.
Benefits of a more targeted prior authorization submissions
By focusing on submitting only the necessary documentation, providers can streamline the prior authorization process. Staff and clinicians spend less time on repetitive data entry and searching for prior authorization requirements.
Furthermore, including only pertinent information with prior authorization submissions allows payers to understand and evaluate the request more easily. This can result in better communication between providers and payers. In turn, this leads to stronger provider-payer relationships and a more efficient prior authorization process.
By simplifying the PA submission and including only the necessary documentation, healthcare providers can increase the likelihood of approval. Payers can more easily assess the medical necessity and cost-effectiveness of the requested treatment, ultimately benefiting both the patient and the provider.
How prior authorization software enables this ‘less is more’ approach
With more than 1,000 payers in the U.S., each with a multitude of plans and policies, manually identifying the exact requirements for prior authorization submissions takes a considerable amount of time and effort.
Myndshft prior authorization software combines automation with Collective Healthcare Intelligence™, a single source of truth for patients’ health and benefits information, providers’ clinical documentation, and payers’ plans and policies. Rather than gathering details from multiple places, providers enter minimal data to get the ball rolling.
Our rules-based payer policy engine helps you go from eligibility and benefits verification to prior authorization submission in 5-6 minutes. That’s a significant time savings compared to 20-60 minutes typical of a manual process. Myndshft also puts an end to over-processed prior authorization submissions, providing the information required by the payer, using the payer’s form and preferred submission method.
It’s true: Less really is more when it comes to prior authorization. By combating the CYA mindset and submitting only necessary documentation, prior authorization software streamlines and standardizes the process. This improves communication with payers and increases the likelihood of approval. Not only does this benefit patients and providers, but it also contributes to a more efficient and cost-effective healthcare system.
Connect with Myndshft to see what’s possible.