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Myndshft Blog

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September 22, 2022

The Most Impractical Tip Ever for Managing Prior Authorizations and What You Should Do Instead

by Susan Lawson-Dawson | Healthcare Technology, Prior Authorization

“The definition of insanity is doing the same thing over and over again and expecting different results.” It may be one of the most famous quotes that Albert Einstein never said (surprised?), but it came to mind recently. The reason?: A tip in Medical Economics for limiting the impact of prior authorizations on primary care, physical therapy, and other provider practices.

Here’s the tip in its entirety:

“Assign a staff member to each payer. This person can become an expert on the payers for which they are responsible, learning their specific expectations and what to avoid. They can also build relationships with their counterparts at the payer, which may help expedite claims and appeals. This person should also create a basic guidebook for each payer that others can follow if needed.”

Did you laugh out loud when you read it? Maybe rolled your eyes a little? Unfortunately, this isn’t a prior authorization meme (yet). Instead, it’s a sign that we still have a long way to go in transforming healthcare because we have to challenge old mindsets.

Now, to be fair, the second tip pointed to the potential of technology, so the list isn’t completely without merit. But the first tip is problematic because it reflects healthcare’s long-held status quo. Let’s break down the problems inherent in this approach.

Establish an Expert for Each Payer’s Prior Authorization Requirements

Raise your hand if you’ve worked in an acute or post-acute care setting where there was a go-to person for payer questions. The Blues Guru, the Cigna Specialist, the Humana Hot Shot—there’s usually one or two on staff. But relying on one individual to know everything about a payer poses multiple problems.

  1. What happens when that person takes sick leave, goes on vacation, or joins the Great Resignation? Your prior authorization process stalls because of over-reliance on tribal knowledge.
  2. How does each “payer expert” keep track of changes? The payer “rules of engagement” around prior authorizations change regularly, so staying alert to new requirements requires constant monitoring—and that staff person has other duties that could fall by the wayside.

Not to mention, with more than 1,000 health insurance companies registered in the U.S., it’s simply not practical. Granted, you may not encounter more than a dozen different payers in your practice, but few healthcare organizations have the budget to have a single staff member assigned for each payer encountered.

Building Relationships Take Time; Prior Authorizations Can’t Wait

While it’s sound advice, the second point is also not much of a solution. Having a good working relationship with a payer colleague does smooth some of the wrinkles in the prior auth process. You might, for example, spend less time on hold if you have a direct line of communication with someone.

But the likelihood of that person being able to expedite claims, troubleshoot denials, or reduce the rework needed when a prior authorization is denied are pretty slim. Why? Because that person has duties to fulfill, and the majority of them have nothing to do with your specific prior authorization questions.

Create a Prior Authorization Guidebook for Each Payer

Did you just think, “Been there. Done that.”? You aren’t alone. Plenty of providers maintain a payer “Bible” with details that staff members can turn to when they run into challenges in the prior authorization process.

Whether you keep all payers in a single binder or create individual guides for each payer, the end result is paper-based and needs constant maintenance to keep it up to date. Not to mention that as the binder grows, finding the exact information you need gets more time-consuming.

Plus, how do you share it? Do you make multiple copies? If so, who is in charge of version control as new information is added? It’s not practical, sustainable or scalable.

Let’s face it: One binder to rule them all is pure fantasy, without the entertainment value of hobbits, dwarves, and elves.

Prior Authorization Software Reduces Reliance on Tribal Knowledge

As mentioned earlier, the article’s second tip was more practical: “Maximize the use of technology.” But it must go beyond using online forms and prior authorization submission portals. Payer portals were supposed to lessen the challenges of prior authorization, but the reality falls short of that vision. Sure, if a payer portal is available, it may save you a few steps to the fax machine or a few minutes on a phone call. (But not all payers have portals.) The repetitive manual data entry doesn’t disappear either. Payer portals are convenient, but they are not a solution for the administrative burden of prior authorization.

When it comes to technology that has a huge impact on prior authorization efficiency, Myndshft can help.

Available to integrate directly in any system of record, Myndshft prior authorization software combines hands-free automation with Collective Healthcare Intelligence™, a single source of truth for patients’ health and benefits information, providers’ clinical documentation, and payers’ plans and policies.

No more relying on a single person to know it all. No more flipping through a binder to find the details you need. Just real-time payer connections, a rules-based payer policy engine, and intelligent automation that reduces the time to determine prior authorization requirements, gather required documentation, submit a prior authorization request and monitor the status from 40 minutes or more to five minutes or less.

Want to see for yourself? Arrange a Myndshft demo.