You don’t have to look far to find evidence of the high administrative burdens faced by healthcare providers. According to JAMA, administrative costs account for 15% to 25% of total national health care expenditures—or $600 billion to $1 trillion a year. From benefits verification to billing, the processes that connect patients to the care they need involves substantial effort, with 88% of providers pointing to prior authorization as a ‘high’ or ‘extremely high’ burden.

Recently, we hosted a panel discussion to talk about benefits verification and prior authorization from a post-acute care perspective. Moderated by our own Tyler Wince, Chief Product Officer, the panelists included:

• Liane Parker, RN, CPHM; CEO of Quantify Remote Care
• Julianne B. Dreon, Senior Director, Revenue Cycle at MedQuest
• Westley (Wes) Bernhardt, Managing Partner, One Path Diagnostics

With each panelist bringing decades of experience to the table, it was an interesting discussion, to say the least. Today’s blog focuses on questions they answered about the benefits verification and prior authorization process. 

Q: How do benefits verification and prior authorization differ in post-acute care, and what does that mean for your revenue cycle?  

Prior authorization is a way for private or public healthcare payers to contain costs while ensuring their members receive medically appropriate care. Typically, it’s clinical data plus demographics data that gets shared with the payer. The payer compares the request against a set of predefined guidelines and then notifies the provider of approval or denial. 

When benefits verification and prior authorization take place within an acute care setting, there’s an immediate advantage of a direct line of sight.  In a post-acute care setting, that isn’t the case. Typically, the insurance companies want the physicians to perform prior authorization requests. 

Most post-acute care, however,  takes place on a referral basis, which places providers like diagnostic labs, radiology labs, home health care, or physical therapists in the middle. Post-acute care providers have to coordinate between the acute care provider’s system to get clinical documentation needed, as well as with the payer’s system to determine if prior authorization is needed and the specific requirements needed for submission.  Wes Bernhardt admits, “We jump through a lot of hoops. At the end of the day, it’s about finding the path of least resistance to get the authorization done quickly.” 

That being said, post-acute care providers “middleman” status can have a direct impact on the revenue cycle. The physician prescribes a set of services to a patient, but it’s that service provider who submits the prior authorization. Since payers want the prescribing physician to submit, that in itself can slow the process down, leading to reimbursement delays or the need to rework claims in response to denials. 

Q: From a process perspective, where are the biggest bottlenecks in benefits verification and prior authorization? 

Lack of consistency in benefits, prior authorizations, and claims

With her experience in direct patient care, payer-side utilization management, and post-acute care delivery, Liane blames a  lack of consistency. “The biggest bottleneck is that on eligibility, prior authorization, and claims, no payer is absolutely the same. It’s very cumbersome and very, very  difficult to navigate, she says. Liane admits, “It was extra frustrating for me because when I was on the payer side, I thought I’d built it quite simply. But now that I’m back on the provider side again, I see barriers and red tape where we have to dig and waste tons of time to locate the appropriate place to go for special plans or payer subsidiaries.” Imagine how challenging it is for someone that doesn’t have both payer- and provider-side experience. 

Lack of clarity plagues post-acute care

Julianne notes another challenge: benefits often differ when it comes to specialty services. “When you run benefits verification and eligibility, initial results turn up generic hospital or outpatient services. I know on the radiology side, we struggle to get the information we need and often rely on vendors that can dig deeper to discover the actual radiology benefits,” she says. 

Julianne prioritizes staffing retention because so much of benefits verification and prior authorization relies on tribal knowledge. Submission requirements aren’t universal for a single payer; they are plan dependent. With scores of payers and plans, it’s not unusual to have a single staff member that is the expert on the “Blues” while another knows the ins-and-outs of Medicare. It takes a lot of skill and knowledge to navigate these complexities, so keeping experienced staff members is critical to keeping the process running smoothly. 

Pace of innovation adds to prior authorization burden

Wes notes that in advanced genomic testing, most tests require prior authorization, either because of the novelty or the cost. When you’re outsourcing this process to vendors, the frequency of new tests and therapies means that the vendors may not have the knowledge and experiences needed to get the job done. “As we continue to get more and more personalized medicine,” says Wes, “this is not going to slow down the amount of authorizations that are required and the uniqueness of these authorizations. At the same time, time is of the essence because these patients are waiting for treatment. And it’s really crucial that treatment happens right away. So you’re stuck between a rock and a hard place.” 

Julianne agrees, “We experience that a lot with interventional radiology.  Getting prior authorization is more intricate, yet, these are patients with the greatest need for a quick process so they can get care.” 

Want to find out how these experienced panelists tackle their own benefits verification and prior authorization hurdles?  Keep watching the Myndshft blog. In the coming weeks, we’ll share more insights from our panelists on current best practices, the regulatory landscape, and their predictions for the future. 

Can’t wait? Check out the full panel discussion, now available on demand.