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May 22, 2023

Taming the Beast: Prior Auth Software Wrangles Constant Payer Policy Changes For You

by Susan Lawson-Dawson | Healthcare Technology, Prior Authorization

Every year since 2016, Medical Group Management Association (MGMA) members have reported an increase in prior authorization requirements. The volume alone poses a big challenge. Add in constantly changing payer policies and keeping pace with the volume becomes even more challenging. Prior auth software overcomes those hurdles by making the information you need more accessible. 

New prior authorization policy ignites concerns

Beginning June 1, UnitedHealthcare plans to introduce prior authorization for colonoscopies. The March announcement, which ironically took place during Colorectal Cancer Awareness Month, ignited concerns among gastroenterologists who say the new policy creates barriers for patients seeking surveillance and diagnostic colonoscopies to detect cancer. 

Gastroenterologists argue that the requirement for prior authorization will hinder access to essential endoscopic procedures. Delays in cancer diagnosis and monitoring, in particular, could lead to poor health outcomes. Daniel Pambianco, president of the American College of Gastroenterology, told StatNews, “The back and forth is very frustrating. We are going through a process where we are dealing with a company practicing medicine without a license. They’re making decisions for patient care, but they don’t see the patient. They’re not a clinician dealing with the patient’s problem.”  

Similarly, Gastroenterologist Linda Lee, MD, medical director of endoscopy at Boston-based Brigham and Women’s Hospital and associate professor of medicine at Boston’s Harvard Medical School told Becker’s via email that “All four procedures that UnitedHealthcare is  requiring prior authorizations for soon have very well documented medical indications for them, and this truly makes no sense and is driving healthcare the wrong way.” 

And it’s not just those in healthcare questioning the policy. An article from Forbes recently covered the upcoming change, noting, “What makes the new policy regarding surveillance and diagnostic colonoscopy particularly controversial is that it goes against the grain of what experts in the field—gastroenterologists, but also health economists—would consider a rational pathway. Erecting barriers to access for those who are at risk and therefore more likely to develop colorectal cancer doesn’t make sense.”

Payer policy changes to prior authorization requirements par for the course

Changes to prior authorization requirements aren’t uncommon, but the frequency and nature of changes varies depending on several factors. 

  • Different payers have different policies and procedures for how frequently they update their prior authorization requirements. Some may make changes on a regular basis (quarterly, biannually, or annually). Others may adjust policies based on outside drivers, such as the next example. 
  • Changes in healthcare laws and regulations can cause payers to adjust their prior authorization requirements. Sometimes changes happen in response to new federal or state laws. When the CMS updates Medicare or Medicaid policies, payers in the private sector—particularly those offering Medicare Advantage plans, often follow suit. 
  • Advances in medical technology, changes in treatment guidelines, or new evidence about the effectiveness of certain treatments can all lead to changes in prior authorization requirements. Such advances contribute to overall volume, as well. Payers introduce new prior authorization requirements in an attempt to manage utilization for newer—but often more costly—treatments, procedures or medications, such as those in the area of personalized cancer care
  • Financial considerations, of course, play a role too. The U.S. health and medical insurance industry market size in terms of revenue hit $1.3 trillion in 2022. As a result, payers often adjust their prior authorization requirements to manage financial risk. Often, this results in treatment delays or abandonment that negatively impact health outcomes for patients. Plus, a 2022 American Medical Association (AMA) survey also found that the prior authorization process led to higher overall utilization in terms of additional office visits, initial use of less effective therapy due to step therapy requirements, ER visits or hospitalizations. 

You need to stay up-to-date with these changes to ensure you can provide appropriate care for your patients and navigate the reimbursement process effectively. This can be a significant administrative burden, and many healthcare providers employ dedicated staff to manage prior authorizations.

How does prior auth software help you keep up with evolving prior authorization policies? 

Software like Myndshft automates the process, reducing a typically time-intensive manual process down to minutes. You enter minimal data and the software takes over. 

To streamline prior authorization, we use intelligent automation combined with 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. 

Graphic showing patient, provider and payer data sources used by Myndshft prior authorization software

Our payer policy library and rules engine removes the confusion from the prior auth process. The rules engine determines if a prior authorization is required based on the patient’s plan. The software pulls in only the most relevant information. Then, the system uses the payer’s preferred form and submits the request via that payer’s preferred method. 

In addition, you can track the status of authorization requests all in one place, rather than visiting numerous payer portals or waiting on hold to talk directly with a payer just to verify status. 

Want to know more about how our software works? Connect with Myndshft today