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Myndshft Blog

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October 17, 2022

Transitioning to Value-Based Care? Prior Authorization Software Can Help

by Susan Lawson-Dawson | Prior Authorization

A push toward value-based care models emerged in 2010 with the passage of the Affordable Care Act. In truth, patient-centered medical homes (PCMH) came about first in 1967. They also saw a resurgence in 1997. But despite decades of value-based care initiatives, the needle hasn’t moved all that far. 

A 2022  study found that only 15% of providers earn more than half of their revenue from value-based care contracts. Meanwhile, 63% report that less than one quarter of their revenue results from value-based care. Below are some ways to accelerate the transition from fee-for-service to value-based care, from patient engagement to prior authorization software

Invest in relationship building with patients

In a nutshell, value-based care reimbursement is based on your patients’ clinical outcomes, not the services you provide. The problem? Patients play a big role in outcomes. If they encounter barriers in following their care plans, it can have a negative impact on outcomes. 

  • Forgetting to take prescribed medications
  • Lack of transportation for follow-up visits
  • Resistance to ‘sticking with the plan’ 

Sometimes, it’s out of your control. But if you build a strong rapport with patients, they may reveal potential red flags, so you can take a more proactive approach. Of course, proactive patient engagement takes time, so you’ll need to free up staff for it. That’s where the next recommendation can help. 

Take advantage of automation with prior authorization software

Eliminating administrative burdens allows you to re-allocate staff to more patient-centric efforts. Prior authorization software like Myndshft lets your staff go from benefits verification to prior authorization submission and tracking in minutes, not hours.  

The software accomplishes this by using best-in-class HL7 FHIR APIs, intelligent automation, and Collective Healthcare Intelligence™—a single source of truth for patient, provider and payer information. 

  • Staff enters minimal information identifying the patient and CPT codes.
  • The prior authorization pipes in necessary patient/clinical data automatically. 
  • Upon establishing that  prior authorization is required,  the software immediately determines what’s needed for submission and the correct form using our proprietary  payer rules engine and policy library. (No more relying on institutional knowledge.)
  • Before submission, the software pre-checks for errors or missing information, reducing the likelihood of preventable denials and rework by 90%.
  • Status of prior authorization requests is available in a single place, eliminating the need to track status across multiple payer portals or by calling payers directly. 

Productivity climbs, allowing you to move staff to other high-value tasks like the next tip suggests. 

Focus your resources where you’ll get the most bang for your buck

As Health economist Duane Feger points out, “Given current staffing constraints across the industry, it’s impossible to provide continuous care to every patient on your panel.” 

Instead, start your patient engagement efforts with high-risk and high-utilization patients.  Feger suggests concentrating your care management efforts on “the cohort of patients that are entering or transitioning through a period of high utilization (e.g.: cardiac/cerebrovascular events, oncology events, etc.).” 

You can establish a protocol to keep patients engaged, one that takes a broad view of treatment rather than the narrow perspective of a single episode of care. And, you can do it incrementally. Pick the highest risk patients or the most complex, high utilization services. Build out a program and evaluate its effectiveness; then clone the program as you expand your efforts. 

Bottom line: With the right technologies and strategies, you  can accelerate the shift to value-based care without decimating your revenue stream. Are you ready? 

Connect with Myndshft to see how prior authorization software works.