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Myndshft Blog

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June 1, 2023

Simplify to Succeed: Solid Strategies for Streamlining Your Home & Specialty Infusion Prior Authorization Workflow

by Susan Lawson-Dawson | Healthcare Technology, Prior Authorization

When it comes to the status quo for prior authorization, today’s process stinks. Complicated on a good day, pursuing prior authorization for home or specialty infusion takes complicated to the next level.  It negatively impacts patient care and places a significant administrative burden on your staff. Plus, delays and denials can slow your revenue cycle to a crawl. By implementing solid strategies, including prior authorization software, home and specialty infusion providers can streamline the process,  improve operational efficiency, and achieve better health outcomes for the patients you serve.  

Complex prior authorization workflow hinders timely care

In its assessment of the infusion care market, The Advisory Board anticipates a continuing rise in volume, thanks in part to the nation’s aging population, new infusion treatments coming to market, and an increased prevalence of chronic disease. In turn, the rising volume has spurred another trend. Payers increasingly favor alternate sites of care, such as home infusion or stand-alone infusion clinics, over hospital outpatient departments (HOPDs). 

Favored status does not equate to no need for prior authorization. Home and specialty infusion providers still have to navigate payers’ utilization management maze. And it’s definitely more complicated. Here’s why: 

Referrals add a layer of complexity

Dealing with a high volume of external referral-based patients increases your dependance on receiving accurate and complete patient and clinical data from the referring physician. Missing information on their part can lead to delays or denials that gum up your scheduling and your revenue cycle. 

Shifting requirements create challenges

As payers’ site of care restrictions and requirements evolve, including the shift of certain injectables from medical to pharmacy benefits makes billing and administration even more difficult. Just tracking down prior authorization requirements can involve multiple visits to payer portals or waiting on hold to speak directly with a payer. 

Home infusion or specialty infusion centers have also witnessed an increase in denials and underpayments by payers trying to manage drug spending. This puts your revenue at risk. 

Give your prior authorization workflow a boost with these tips

As your patient volume climbs, so does prior authorization volume. What strategies prove effective at lightning the load?

Establish a prior auth triage role

Our introduction to the  benefits of a prior authorization triage role came from a revenue cycle leader at a multi-state physical therapy provider. He recognized early on prior authorizations led as the #1 cause of denials. By assigning one person to “triage” denials, the organization improved visibility into the types of preventable errors that kept prior auths from getting approval the first time. The triage person reviews all denials, identifies the causes of preventable errors, and takes responsibility for providing staff members with details on how to prevent those errors. As a result, preventable errors declined by 39%.  

Educate and empower your staff

Investing in staff education and empowerment is crucial for a simplified prior authorization workflow. Continuous training programs, workshops, and access to up-to-date industry information and best practices ensure that staff members are well-equipped to navigate the complexities of prior authorization effectively. Empowered staff can confidently handle the process, resulting in reduced errors, improved accuracy, and expedited approvals.

Go a step further with automated prior authorization

The volume of prior authorizations keeps growing. Unfortunately, you can’t just throw more people at the problem because many organizations remain short-staffed. Adding staff also impacts your bottom line, so that’s not the answer. 

Prior authorization software like Myndshft automates a time-consuming process, reducing turn-around time while improving accuracy of submissions. Using industry-leading FHIR APIs enables fast, seamless exchange of what we call Collective Healthcare Intelligence™—a single source of truth for patients’ health and benefits information, providers’ clinical documentation, and payers’ plans and policies. 

You enter minimal information and the software does the rest, using intelligent automation. Instead of time-consuming searches to discover if prior auth is required and what submission criteria is needed, the software leverages an extensive payer policy library and rules engine that quickly identifies prior authorization requirements. From there, APIs serve as pipelines to deliver the data into the appropriate form and submit the request via the payer’s preferred method. 

You can go from eligibility and benefits verification to prior authorization submission in just minutes. Plus, it reduces preventable errors and removes the rework that comes from missing required data and supporting documentation, which lowers operational expenses. Imagine what you could do by clawing back the time spent on manual prior authorization. Your staff can focus on more rewarding work, rather than tedious data entry. Your patients get connected to the care they need sooner. And your revenue cycle evens out. 

Prepare for growing demand for long-term success

Streamlining the home and specialty infusion prior authorization workflow frees you from a notorious administrative burden. Simplifying the process using any or all of the strategies noted can ultimately lead to increased operational efficiency, higher staff satisfaction, and improved health outcomes for patients. Because when that happens, a more robust bottom line won’t be far behind. 

See how Myndshft can help. Connect with us to arrange a demo