Why Communication Is So Critical to the Prior Authorization Process & How Interoperability Will Help
“Good communication is the bridge between confusion and clarity.” This quote may have originated in the 1800s, but it seems particularly relevant to some of the benefits verification and prior authorization challenges healthcare providers face, particularly in post-acute care settings from home health and physical therapy facilities to radiology and diagnostic labs.
Those prior authorization challenges were a recent topic here, inspired by a panel discussion we hosted. Now, let’s dive into what helps bridge communication gaps: interoperability.
Why interoperability matters
Interoperability is a common goal (and challenge) across healthcare, and post-acute care is no exception. It’s been slow going:
- Fewer than 4 in 10 health systems can successfully share data with other health systems (Fierce Healthcare)
- Four in 10 say interoperability challenges limit their organization’s effort to improve workflow and enable new models of care (Fierce Healthcare)
Our panelists have definitely experienced those frustrations. Julianne B. Dreon, Senior Director, Revenue Cycle at MedQuest recalls how an early attempt to automate prior authorization turned into a fail. “The way that payers interacted and sent information back and forth became more problematic than just going back to the old fashioned way,” she notes. Despite how intensive manual prior authorization is, the inability to communicate easily between different payer systems, as well as the lack of uniformity from payer to payer, made her first foray into automated prior authorization disappointing, to say the least.
Co-panelist Liane Parker, RN, CPHM; CEO of Quantify Remote Care, knows the frustrations of poor communication. “It takes a significant amount of time to figure out the right answer to a question, only to get contradictory information,” she says.
One of the biggest hurdles in using technology to alleviate administrative burdens and improve healthcare access is moving data from one system to another, quickly and securely. But as No. 11 on the American Film Institute’s top 100 movie quotations goes:
“What we’ve got here is failure to communicate.”
~ Captain, Cool Hand Luke
That’s because the healthcare industry is still in the early stages of interoperability. But not for long.
Where interoperability is headed
The Healthcare Information and Management Systems Society (HIMSS) has made its mission to “reform the global health ecosystem through the power of information and technology.” HIMSS breaks down interoperability into four levels:
- Foundational: Putting requirements in place that facilitate secure data exchange between systems across the healthcare ecosystem.
- Structural: Creating consistency in the “format, syntax and organization of data exchange,” down to the data field level to make results easier to interpret.
- Semantic: Improving clarity by standardizing language and definitions for data elements common to various use cases, so everyone is working from a shared understanding.
- Organizational: Establishing a framework for “governance, policy, social, legal, and organizational considerations” to make more efficient, secure communication and use of data possible.
The foundational work, which is well underway, includes expanding use of HL7Ⓡ FHIRⓇ APIs to allow secure, fast data exchange between disparate systems. Likewise, the DaVinci project covers much of the structural and semantic work that needs to be done.
What’s being done on the organizational level? We asked our panelists the same question.
Retention key when interoperability lacks
The importance of staff retention cannot be overlooked. Until information flows consistently between providers and payers, keeping your valued staff (and their hard-to-replace knowledge) is critical, says Julianne. In post-acute care it can be especially important because smaller organizations often use homegrown EHRs.
While such systems offer benefits, such as customization for a particular type of care, they also present challenges. Since it’s not the norm, for example, it can take longer for new staff to get up and running on the unfamiliar EHR. Plus, homegrown systems need constant maintenance; something you don’t have to worry about when you buy your technology solutions.
AI and automation speeds data exchange
The next items on our list—automation and AI (artificial intelligence)—can actually help with retention. Automation frees your staff from tedious, repetitive data entry, enabling them to move on to more rewarding work. In addition, because data exchange is automated, there’s less room for errors that can lead to prior authorization denials and rework.
In her former role with a PBM (pharmacy benefit manager), Liane was looking for ways to streamline and automate the prior authorization process to drive down provider abrasion. That’s when she had her first introduction to Myndshft. Now that she is leading a post-acute care organization, she relies on Myndshft to help automate her process.
Panelist Westley (Wes) Bernhardt, Managing Partner of One Path Diagnostics, sees even greater potential in combining interoperability with artificial intelligence (AI). “I’ve got to believe that AI is going to play a role here. As we continue in the future to learning, reasoning, AI is going to be a great opportunity for savings in time and costs. As AI continues to learn what to do and what not to do, it’s going to be extremely helpful towards the future.”
Prior authorization does not have to be as burdensome as it is. With the right people, processes and technologies in place, clear communication is just a few clicks away.
If you’d like to see what’s possible with automation and AI, contact us.