In early April, HealthDay reporter Dennis Thompson wrote, “Much has been made of burnout among doctors and nurses, but a new survey has found high rates of work fatigue in nearly every type of job associated with healthcare.”  His comments refer to a recently published report in the Journal of General Internal Medicine.  The report found similar burnout rates among all healthcare workers: 

• 47% of physicians
• 56% of nurses
• 54% of clinical staff
• 46% of non-clinical staff

One of the biggest reasons? Prior authorization. Fortunately, that’s a solvable problem with the help of prior authorization software. First, let’s look at what the problem entails. 

Prior authorization burden keeps growing

When the Medical Group Management Association (MGMA) released the results of its 2022 Regulatory Burden Survey last fall, Anders Gilberg, SVP of Government Affairs at MGMA said, “The increase in prior authorization requirements year after year is simply unsustainable.” 

Unsurprisingly, the survey revealed that 89% of respondents said they had to hire or reallocate staff to work on prior authorizations due to the rising requests. In fact, among regulatory burdens, prior authorization led the way, followed closely by compliance with the No Surprises Act and with Medicare’s Quality Payment Program.  

Administrative tasks reduce direct patient interactions

Physicians and other clinical staff find the back-and-forth particularly frustrating. An op-ed written by neurosurgeon Richard Menger, MD, MPA, FAANS and nurses Jessica Murfee, RN, BSN and Erin Roberts, RN, BSN, discusses the challenges that a cumbersome prior authorization poses. Just identifying whether a service or medications requires prior authorization takes effort, often requiring multiple visits to payer portals, calling the payer and/or old-school binders. 

Once a request is submitted, delays and denials lead to more work for clinicians—and not the patient-facing kind. “Instead,” the authors explain, “our nurses have to spend time regurgitating what is already in the chart to an insurance representative. Most of the time, it’s an administrative clarification issue, but calling into the insurance abyss is like dialing into a time warp.”  Time nurses spend navigating prior authorization roadblocks could be better utilized on direct patient interactions, like offering tips to help patients prepare for an upcoming procedure. 

Legislative solution for prior authorization burden stalls, regulatory changes move forward

When the House passed the Improving Seniors’ Timely Access to Care Act in 2022, the healthcare industry buzzed. Finally, the prior authorization burden was going to be addressed. Despite bi-partisan support, however, the legislation stalled in the Senate after Congressional Budget Office analysis suggested that utilization increases and technology adoption would raise costs in excess of $16 billion over a decade.  

From a regulatory perspective, however, change is on the horizon. The public comment period recently ended for a proposed rule by the Centers for Medicare & Medicaid Services (CMS). The Advancing Interoperability and Improving Prior Authorization Processes Rule (CMS-0057-P) aims to streamline the prior authorization process, standardize data exchange and improve interoperability between healthcare stakeholders. Among other things, the proposed changes will require: 

• Use of a standard electronic format for prior authorization requests and responses, thereby reducing administrative burdens and improving efficiency.
• Use of a secure, standards-based application programming interface (API) to allow real-time exchange of patient-specific benefit and cost-sharing information between providers and payers.  
• Establishment of a process for providers to submit prior authorization requests electronically, including through an API, and would require payers to respond to those requests within a specified timeframe.

In addition, the rule would create penalties for payers that fail to comply including potential fines and suspension of enrollment.

AI-supported prior authorization software relieves the pressure

As RevCycleIntelligence notes, “The prior authorization process is one of the best use cases for AI in healthcare. Prior authorizations are a resource-intensive task that requires providers and payers to comb through clinical and administrative data to build a case for approval or denial.”  But you don’t have to wait for regulations to achieve streamlined prior authorization. 

Myndshft prior authorization software already uses the Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard APIs that the CMS has proposed in its pending rule. When combined with intelligent automation and our extensive payer policy library and rules engine, prior authorization software quickly navigates the complexities of prior authorization. It takes a process that involves repetitive data entry, time-consuming research, and frustrating phone calls and shrinks it. 

Providers enter minimal data and the software does the heavy lifting. Instead of spending 20-60 minutes per manual prior authorization, you can move from eligibility and requirements determination to prior authorization submission in 5-7 minutes. 

Plus, instead of visiting multiple payer portals to check status of prior authorizations, you can see everything in a single dashboard for added convenience. 

Nothing can banish burnout completely. After all, working in healthcare is intense, and the last few years have been particularly tough. But by removing one of the biggest stressors weighing down clinicians and non-clinical staff alike, prior authorization software delivers real value for providers, payers and the patients they serve. 

Want to get started with prior authorization software? Connect with Myndshft today!