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October 11, 2022

Why Keeping Up With Prior Auth Requirements is So Hard (And How Prior Authorization Software Helps)

by Susan Lawson-Dawson | Prior Authorization

Have you ever googled ‘prior authorization changes 2022’? (Go ahead, try it.) On any given day, the results are astonishing—anywhere from 76 million to over 100 million in half a second. Is it any wonder that the pursuit of prior authorization remains frustratingly slow?  Especially if, like many providers, you rely on a manual process rather than prior authorization software

Before diving into how prior authorization software solves the problem, let’s look at why requirements determinations pose such a challenge. There are two big reasons. 

State rules for prior auth requirements vary widely

Some states have introduced or passed legislation to rein in the administrative burden for prior authorizations on healthcare providers. 

In Indiana, payers are required to list prior auth requirements by CPT code on a website or portal, including the criteria required for submission. In addition, payers must conspicuously disclose new prior auth requirements 45 days prior to implementation on the web.

Minnesota goes a step further. The state mandates that payers provide 45-day electronic notice of new or amended requirements to all Minnesota-based, in-network attending providers. But some states don’t address the issue of changes to prior authorization requirements or clinical guidelines at all.

Recently, Congress has taken up the issue of prior authorization transparency too. The “Improving Seniors’ Timely Access to Care Act” has already passed a House vote and appears to have strong support in the Senate too, with 42 Senators co-sponsoring the bill.  Legislative efforts will take some time, however, so the problem won’t disappear quickly. Without consistency and transparency, discovering if a procedure or medication requires prior authorization comes down to a lot of manual detective work done on the web or by phone.  

TIP: You may gain a slight advantage by prioritizing efforts based on procedures or medications that due to volume or value have the greatest impact on your revenue stream. While it reduces risk of denials among the targeted services, it fails to bring the full visibility needed to eliminate preventable denials. 

Prior auth requirements keep expanding

With more than 1,000 registered payers in the U.S., each with numerous plans, the number of unique prior authorization requirements easily surpasses the million mark. Add in frequent changes and a lack of standardization, and providers in both acute and post-acute care face typical dilemmas associated with big data: volume, velocity, and variety. 

Manually keeping track of every requirement? It’s next to impossible, regardless of how many staff members you throw at obtaining prior authorizations. And, given the current hiring challenges, few providers have the resources to dedicate to such efforts. 

Lacking visibility into requirements puts a strain on your organization and your patients. If you miss that prior authorization is required, you have to cross your fingers, attempt to get retroactive approval or forgo reimbursement—either of which plays havoc with your revenue cycle. 

Likewise, if you can’t easily determine the criteria required with submission, prior authorization requests may wind up denied, leading to treatment delays or abandonment. 

Prior authorization software speeds up the process

As labor costs rise and margins shrink, addressing administrative costs ranks high on providers’ to-do lists. Collectively, costs attributed to administrative tasks—from patient intake to collections—reaches between 15% to 30% of total U.S. medical spending. What’s even more frustrating, says a Health Affairs research brief, is that at least 50% of administrative spend “… does not contribute to health outcomes in any discernible way.” 

That’s where prior authorization software can help. Instead of the productivity drain of repetitive manual research and data entry, the entire process—from benefits verification to prior authorization status monitoring—runs automatically, with minimal data entry. This frees up staff for more rewarding, high-value tasks. 

So how does prior authorization software help specifically with requirements visibility? It connects the dots between provider, patient, and payer data. 

Myndshft, for example, has built an extensive payer policy library and an AI-powered rules engine that updates prior authorization rules for hundreds of payers—and more are always being added. What’s this mean for you? 

  • Less reliance on out-dated “Payer Bibles” and institutional knowledge 
    Myndshft continuously compiles payers’ medical policies and guidelines to maintain the library, which can increase productivity up to 25%. 
  • Patients get prior authorizations sooner
    Myndshft automates identification of policy-specific prior authorization requirements, as well as a payer’s preferred submission method. This contributes to a 90% reduction in prior authorization cycle time.

The library is just one part of a bigger set of data that we call Collective Healthcare Intelligence™.
Diagram of Collective Healthcare Intelligence
Using automation and the rules engine, the software automatically fetches relevant patients’ health and benefits data, payer policies and requirements, and provider fee schedules to speed through tasks critical to your revenue cycle. That means you can fly through benefits verification, insurance discovery, patient financial responsibility calculation, and, of course, prior authorization—in minutes, not hours or days. 

See what’s possible with Myndshft.