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Prior Authorizations

21st Century Consumerism

21st Century Consumerism

The 21st Century is a marvel of information technology moving at the speed of light.

Today's consumer is well informed, more so than any other time in history due to the improved communication that comes from the internet, apps, and social media platforms. With the increasing amounts of information available today, businesses have noticed an emerging hyper-consumerism in today's marketplace. Consumers spend more time researching the purchase of a good or service now than ever before. One of the most prolific industries examined by today's consumers is the healthcare industry.

With rising insurance premiums, many consumers are opting for high-deductible health plans. However, because of the higher upfront cost of healthcare that comes along with these high-deductible plans, many people forgo or delay their medical care. The effect of the delay in treatment can lead to more extensive treatment needed which in turn will be costlier for the patient. With the increased out-of-pocket cost, many people in today's society have problems paying medical bills.

The combination of higher patient responsibility and patients struggling to pay medical bills requires healthcare providers to change their approach to the healthcare revenue cycle. With 84% of physicians stating the prior authorization burden has increased*, evaluating the authorization process as a significant part of the revenue cycle is compulsory in today's economic climate.

The simple issues of receiving prior authorization from the insurance companies and not knowing a patient's true financial responsibility at the time of their appointment lead to an increase in bad debt and a decrease in patient satisfaction. Despite the many improvements in healthcare and technology, obtaining prior authorization for medical procedures is most often a time-consuming and manual process. The staff member must call the payer or interact with the payer's website and then follow up until they receive a decision. Approximately 64% of physicians who participated in a separate survey conducted by the American Medical Association** reported that their practices wait for a minimum of one business day and 30% report waiting at least three business days for prior authorization decisions before the patient is scheduled for their procedure. These delays in prior authorizations also lead to a 92% overall delay ** in care. This same report ** states that 78% of the physicians surveyed reported that the patients abandoned treatment at a higher rate than those who received authorization within less than one business day. Today's patients have a limited time for medical procedures and will seek out other resources (walk-in clinics, holistic care facilities) who can attend to them in a timelier fashion. All of these factors together will inevitably cause a decrease in patient satisfaction.

This manual authorization process is inefficient and has a significant cost assigned to it. Aside from the staff hours needed to process prior authorizations, a large percentage of all denials are the result of authorization or patient registration issues. Factor in the cost of personnel to complete the process a second time which will also then increase the wages paid out by medical facilities and physician practices.

Interestingly, the same technology that contributes to this problem may also be the technological solution we can embrace. As with many of today's everyday tasks, Artificial Intelligence and automation could very well be the answer to the revenue cycle and patient satisfaction problem. With today's technology, we receive a quote for the newest electric automobile or obtain permission to visit a foreign country by merely filling out a simple form.

So why can't we automate the prior authorization process and know what the patient's financial responsibility is while they are standing at the reception desk?

There are software systems available today that can do just that.

Thanks to automation, your hospital, practice, or radiology center can now automate the prior authorization process as well as work out financial arrangements with the patient at the time of the visit.

The prior authorization workflow traditionally involved three steps: determination, submission, and status. For the authorization process to be fully automated, the right software program must automate all three stages. The right software must include the rules for authorization from all payers and must be kept up to date. To ensure that claims are approved, there must also be a check to determine medical necessity in each case submitted. The software must process the submission and be able to receive the appropriate status and payment information in real-time.

Thankfully, the same technology that we cursed at the beginning of this post can now save us. The nightmares of physicians everywhere can now be scrubbed of the twin monsters of prior authorization and payment solutions. Slain is the twin monsters of prior authorizations and patient payments, and patient consumerism is addressed in a positive-and ultimately profitable-manner.