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Myndshft Blog

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November 15, 2023

The Intersection of Prior Authorization and Value-Based Care: Leveraging Software for Success

by Susan Lawson-Dawson | Healthcare Technology, Prior Authorization

As healthcare continues its value-based care (VBC) journey, the need to optimize inefficient administrative processes remains acute. Prior authorization software offers a clear path, helping providers cut through the time-consuming maze of manual efforts with a streamlined, automated process.  How does leveraging a unified platform for medical and pharmacy prior authorizations support value-based care?

Pandemic a catalyst for VBC momentum

Unlike traditional fee-for-service (FFS) models, value-based care focuses on patient outcomes and rewards healthcare providers for efficiency and effectiveness. And, based on new data recently reported by RevCycle Intelligence, adoption of VBC models is climbing.  The article notes, “Over half of healthcare payments last year were made through value-based reimbursement models, with most of those payments tied to some degree of financial risk.”  

One reason? Industry expert and program director for nonprofit Catalyst for Payment Reform (CPR), notes, “The pandemic taught us about the fee-for-service system.” When facilities and service lines were shut down during the public health emergency, one flaw in FFS became patently clear: it is an unpredictable financial model in times of crisis. And not just when the crisis happens on a global scale. Disruptions caused by anything from a natural disaster to a cyber attack can have an impact on revenue when it leads to temporary closures or unpredictable care delays. According to research, capitated payments could lead to more predictable revenue streams, making it easier to navigate disruption. 

Prior authorization inefficiencies hinder the VBC transition

While the VBC model aims for streamlined care and improved patient outcomes, prior authorization remains a process rooted in the fee-for-service world, creating friction and delays. This mismatch can lead to:

  • Administrative burdens that pull resources away from patient care.
  • Delays in treatment that may negatively affect patient outcomes.
  • Conflicts between care providers and insurers over what constitutes necessary care.

Fortunately, prior authorization software serves as a bridge between the traditional, mostly manual authorization processes and the goals of value-based care. Here’s how:

Facilitating efficient care coordination

With VBC, care coordination is essential to creative effective care journeys for patients. Prior authorization software:

  • Integrates with Electronic Health Records (EHRs) to ensure seamless information flow.
  • Streamlines communication between all parties involved in patient care.
  • Reduces duplication of services by facilitating transparency of patient care and authorizations along the care continuum.

In addition, it enables providers to present data-backed cases to payers for certain care paths, aligning with VBC principles.  

Enhancing experiences for patients and staff alike

A smooth prior authorization process directly affects patient experience, which is a key metric in VBC. Automated prior authorization contributes by:

  • Reducing wait times for approvals so patients get the care they need, sooner.  
  • Providing patients with clear information about their care plans, what is covered and what their financial responsibility is—at the point of care.
  • Easing the burden on overworked clinicians and staff so they can focus on patients, not paperwork. 

Supporting data-driven approvals

Prior authorization software also supports approvals by:

  • Allowing for adaptive learning where the software improves its decision-support algorithms based on past approvals data.
  • Integrating with payer systems to align approval processes with VBC objectives.

A value-based care future demands efficient prior authorizations 

As the healthcare landscape becomes more complex, a unified platform that can handle the nuances of medical and pharmacy prior authorizations represents an indispensable tool. To effectively leverage prior authorization software in the context of VBC, collaboration across the healthcare industry is critical. 

The intersection of prior authorization and value-based care is where efficiency meets efficacy. By leveraging automation and collective healthcare intelligence, providers can not only navigate the inherent complexities inherent, but also emerge with improved patient outcomes and cost savings. Prior authorization software is not just an administrative tool; it’s an integral component of a quality-focused healthcare system. As we continue to move towards a more value-centric healthcare model, prior authorization software supports this paradigm shift, ensuring that the focus always remains on delivering high-value care to every patient. With thoughtful implementation and a commitment to ongoing improvement, prior authorization software can help providers shift to new standards in healthcare excellence.

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