Prior authorizations (prior auths or PAs) are a cost management tool utilized by insurance companies. PAs increase administrative costs for HCPs and create a healthcare obstacle for patients. HCPs depend on prior authorization approvals and insurance payments to remain in business. Healthcare providers (HCPs) must master a productive prior authorization workflow to improve productivity and revenue.
The process of PA approval begins when a prescriber requests coverage (i.e., payment) for a particular medical service. After submitting the request, the patient and provider wait for the insurance company to decide.
The prior authorization waiting period creates provider frustration and prevents patients from receiving timely care. A 2021 American Medical Association (AMA) survey found that 93% of physicians reported delayed access due to prior authorizations. 82% of physicians said it even led to patients abandoning treatment.
HCPs and their staff spend 13 hours a week completing PAs. Insurance companies claim PAs control costs. However, there is evidence that PAs increase healthcare costs. For instance, an American Society for Radiation Oncology (ASTRO) survey discovered that PAs cost radiation oncology clinics about $40 million yearly.
Undoubtedly, PAs are a burden for both patients and providers. What can HCPs do to improve the PA process for patients? Here are four tips for improving prior authorization workflow.
1. Be Proactive
Understanding PAs and preparing for the process ensures enhanced PA approval rates. Improving PA approval rates requires foreseeing required documentation and implementing strategies to streamline the process. Here are some tips for a proactive approach to PAs:
- Create a master list of authorization-required procedures
- Obtain authorization at least 72 hours before the patient has a procedure.
- Record reasons for PA denials.
- Subscribe to the payor newsletters
- Stay up-to-date on PA industry standards
- Organize payor contacts into a quick reference guide
- Educate patients on the PA process
In addition to these strategies, the PA process is more efficient and effective when providers embrace technology.
2. Embrace Electronic Prior Authorizations
Traditionally, PAs have been submitted by fax or phone. However, an increasing number of providers are using electronic prior authorizations (ePAs). ePAs are the electronic transmission of information between the prescriber and payer to determine whether or not a PA is approved.
When providers submit an ePA, patients receive medication 13 days sooner than if the PA was submitted by fax or phone. HCPs have been slow to adopt ePAs, but studies have indicated increased rates of PA approval when ePAs are used.
ePAs significantly reduce the manual burden of PAs.2 ePAs improve providers’ ability to attach supporting clinical documentation, reducing PA denial rates. However, these features are often overlooked. Consequently, hiring or training team members to become prior authorization specialists is still essential for a practice to optimize its PA process.
To adopt ePAs, HCPs can use insurance provider portal tools, Surescripts, or CoverMyMeds.
3. Analyze With Metrics
- Verification of Benefits/Collecting co-payments should be 100%
- Pre-Authorizations should be 100%
- A clean claim submission rate of 95+% is best
- A denial rate below 5% is ideal
- Adjusted Collection Rate should be 98%
- The reimbursement ratio should be equal between closed claims and overall claims.
- Ensure the negotiated fee schedule is appropriate (100% is optimized)
Hiring a prior authorization specialist is the best solution when PA metrics aren’t optimized.
4. Hire a Prior Authorization Specialist
For HCPs, hiring a prior authorization specialist has the following benefits:
- Enhances efficiency
- Allows more time with patients face-to-face
- Improves patient satisfaction
- Reduces staff burnout
- Increases revenue
By certifying staff, a practice ensures the PA workflow is optimized and patients receive the best healthcare. To learn more about the Prior Authorization Certified Specialist (PACSTM) program, visit the National Board of Prior Authorization Specialists website.
1. MediGain. Top 8 Metrics To Maximize Your Practice’s Revenue. https://cdn2.hubspot.net/hub/207376/file-2479638322-pdf/docs/eBooks/Top-8-Metrics-to-Maximize-Revenue.pdf?t=1484679252160.
2. Psotka MA, Singletary EA, Bleser WK, et al. Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative’s Prior Authorization Learning Collaborative. Circ Cardiovasc Qual Outcomes. 2020;13(7):e006564. doi:10.1161/CIRCOUTCOMES.120.006564.