Rev Cycle 911: What is Prior Authorization Triage and Why is it an Antidote for Preventable Denials?
If you grew up in the 1970’s, your first introduction to “triage” probably came from MASH, the popular TV series about life at a Mobile Army Surgical Unit during the Korean War. Triage was part of nearly every episode, as nurses and doctors quickly assessed and prioritized care for the wounded. Recently, we spoke with a revenue cycle leader who shared a different use for triage: reducing prior authorization denials and the associated financial losses caused by postponed or unreimbursed care. It’s a useful and effective strategy if you haven’t yet automated your process with prior authorization software. Let’s take a closer look.
Industry-outsider perspective inspired prior authorization triage role
Ricky Overton didn’t begin his career in healthcare. He owned and operated a restaurant. After shifting to medical billing for a decade, he took on a revenue cycle role with a multi-state physical therapy practice. He recognized very quickly that he needed to stem the tide of revenue losses resulting from prior authorization denials. “Prior authorizations led as the #1 denial bucket, and overall, denials were costing between $250K to $400K+ in losses across the business,” he explains.
Ricky realized that a strategy from running a restaurant could prove very useful: expeditors. In the restaurant business, getting quality food to the customers quickly is a top priority. But if the wait staff is always checking on the cooks or vice versa, performance suffers both in the kitchen and the dining room. expeditors kept both the front and the back of the house running smoothly.
In a healthcare setting, however, he needed more than a facilitator; he needed someone who could take all the denials, assess the causes and provide details on how to fix prior authorization requests to the responsible staff members. That’s when Ricky created the prior auth triage role.
What does the prior authorization triage role entail?
Prior auth triage puts the responsibility for troubleshooting denials in one person’s hands. Each day, the triage person would receive a list of denials from 224 clinics across 7 states. By keeping a narrow focus, the triage person identified frequent causes of denials and educated those submitting prior authorization requests on how to fix and ultimately prevent those types of errors.
The role proved very successful. In the first year alone, the triage process reduced losses from rejected claims by $250K. As the error rate declined from 40% to 1%, prior authorizations moved from the #1 cause of denials to #5. “Over time, prior authorization triage became more proactive, rather than reactive, enabling us to continuously improve our submissions with loss reduction climbing to $400K+ annually,” Ricky notes.
The triage person became familiar with the utilization management (UM) teams with different payers. By befriending the UM nurses, the triage person received valuable input on the precise documentation needed. Just as missing information would trigger a denial, too much information would slow the review process or lead to a denial. Working more collaboratively ensured delivery of clean prior authorization requests. As a result, the organization reduced the number of prior authorization requests requiring medical review by 75%. In turn, this accelerated the approval process, allowing patients to get the care they needed sooner.
Prior authorization software becomes the next logical step
While the triage role proved successful, Ricky recognized that a manual process, no matter how efficient, has limitations. He expects he could have realized even more efficiency if the triage role took full responsibility for identifying problems and resubmitting prior authorization requests, however that would have required adding more people to the role.
“You can only throw so many people at a problem; eventually you need to automate to make it sustainable,” he says. He developed in-house a software application to streamline the benefits verification process, including overnight batch processing. He also began development of an app to do the same for prior authorizations. After struggling to achieve the desired results, he recognized that the process was too complex to solve without a lot more development time and improved interoperability. That’s when he was introduced to fully-automated, end-to-end prior authorization software from Myndshft.
Now guiding the revenue cycle for a physiotherapy start-up, Ricky recognizes that establishing a strong revenue cycle process is the first priority. Then you can streamline it with the right technologies. Automating prior authorization delivers long-term revenue cycle benefits, but not without a solid foundation of processes and well-informed staff. Even absent technology, the prior auth triage role remains a solid way to reduce preventable denials and expedite patient care.
Want more proven strategies for revenue cycle stability? We’ll be sharing more from our conversations with Ricky soon. Subscribe to our blog to stay in the know.
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