In the dynamic landscape of healthcare, inefficiencies cost everyone time and money. When it comes to prior authorization, those shortcomings contribute to friction between payers like you and your networks of healthcare providers and members. In an Op-Ed in Becker’s Hospital Review, Northwell Health President & CEO Michael J. Dowling wrote, “To sustain our delivery system, the future of healthcare must include productive partnerships between providers and payers. Without increased cooperation, we’ll continue to be adversaries and everyone, including patients, will suffer.” 

As with Goldilocks and the Three Bears, the key to success lies in finding the “just right” balance between managing utilization to keep costs in check and enabling positive health outcomes for members.  Automated prior authorization serves up the perfect porridge, offering a trio of advantages that streamline processes, minimize abrasion, and bolster satisfaction for both providers and members.   

The Provider’s Tale: Just the Right Amount of Information

Remember how Goldilocks tried bowls of porridge that felt too hot, too cold, and just right? Similarly, when providers apply for prior authorizations, they often grapple with what information is enough, what’s too much, and what’s too little. It’s a precarious balance, but automation from the provider’s end helps find that sweet spot. 

Automated prior authorization guides providers through the request process, using an extensive payer policy library and rules engine to ensure that prior auth requests contain exactly the information you need—no more, no less. This precise tailoring of information reduces the need for back-and-forths, expedites claims, and makes life easier for everyone involved. The software eliminates preventable errors, paving the way for more efficient claims reviews, saving both parties valuable time and resources.

The Payer’s Tale: Clinical Decision Support for Equitable Healthcare

In stories, it’s not uncommon to see a wise elder offer sage advice to the hero or heroine of the tale. Well, consider prior authorization software with built-in clinical decision support as that guiding force for payers. This technology leverages evidence-based guidelines, offering real-time advice that allows payers to make more consistent and equitable decisions. It’s not magic, but it feels close. This level of standardization and objectivity fosters a more equitable healthcare system. This helps ensure that each member is evaluated using the same high standards of medical evidence. Prior auth software’s built-in clinical decision support offers a compass for fair and evidence-based decisions, contributing to health equity and improving provider-member relationships.

Auto-Adjudication: Streamlining Future Authorizations

In fairy tales, once a riddle is solved or a lesson learned, the protagonist finds an easier path ahead. Similarly, as you gain experience with an automated prior authorization system, you can start leveraging its data-driven intelligence to make future processes even smoother.

Based on historical data and decisions, you can set the system to automatically approve requests that fit a certain criteria. If 100% of similar prior requests have been approved, why not auto-adjudicate the next one or even batch of requests? This proactive approach streamlines administrative tasks and speeds up care delivery, leading to heightened satisfaction among both providers and members. Auto-adjudication based on past decisions simplifies the approval process, making healthcare more efficient and satisfying for everyone involved.

Fairy tale ending or fractured future: The choice is obvious

By applying automation to the prior authorization process, payers and providers resolve the biggest efficiency barriers with a “ just right” solution. This makes it easier to work harmoniously for the benefit of members. As Dowling opined a few years ago, “If providers and payers don’t resolve this tug-of-war on their own, politicians and regulators will end up getting involved, which would undoubtedly lead to increased regulation.” That writing is already on the wall. 

But with a solution like Myndshft prior authorization software, providers and payers can get on the same page. It doesn’t just boost efficiency. It gives you powerful tools to enhance health equity and satisfaction across the board. So, why settle for less when automation can offer a happy ending for all?

Ready to turn fantasy into reality? Connect with Myndshft to arrange a demo.