Increase Revenue and Improve Patient Experiences through Streamlined Prior Authorizations Processes

Navigating prior authorizations (PAs) is increasingly challenging as healthcare evolves. While PAs are in place to ensure the appropriate use of medications, procedures, and services, they present significant roadblocks for healthcare providers, staff, and patients. This American Medical Association survey shows many of the challenges faced by providers and patients due to prior authorization workloads. Many providers aren’t adequately staffed to handle their prior authorization workload, causing delays efficiently, errors, and lost revenue opportunities. One solution: outsourcing prior authorization work offers benefits for healthcare systems, including improved patient experiences and profitability.

Consider the challenges of a patient needing a medical test or service that requires prior authorization approval.

• Delays in paperwork submission to the insurance company postpones scheduling the service and treatment.
• The patient becomes responsible for the medical bill because their insurance company did not approve the service.

These outcomes result in poor patient experiences, delayed (94%) or abandoned (78%) treatment according to the AMA survey, and frustration with the provider.

In the same prior authorization scenario, the provider is working through:

• A lag in paperwork processing which translates to payment delays and unhappy patients.
• The patient who realizes they have not received the prior authorization cancels the service at the last minute, resulting in scheduling gaps and downtime for the provider.
• Potential patient leakage and cash flow challenges that can occur over time.

 The Impact on Today’s Healthcare Organization

As each insurance company determines its requirements for prior authorizations, the provider is responsible for staying informed about policies and updates. The current process creates complications that trickle down from the provider to the patient, including administrative burdens, delayed care, and financial implications. Organizations that rely on outside experts minimize complications and improve revenue through outsourcing prior authorization activities.

Expertise and Efficiency

When providers outsource prior authorization tasks to a specialized third-party vendor, they leverage the partner’s expertise and experience navigating the complex, ever-changing landscape. These vendors have dedicated teams trained to manage prior authorization requests efficiently, reducing delays and improving approval rates.

Insider Advice: Look for an organization whose teams are certified CPCs; this level of training will maximize first submission approval rates and ensure that your organization remains compliant against fraud & abuse.

Cost Savings

Outsourcing can lead to significant cost savings by reducing in-house staff’s need to focus on time-consuming and labor-intensive prior authorization tasks. According to the AMA 2023 Survey, “95% of physicians report that PAs somewhat or significantly increase physician burnout.” Internal staff that juggle administrative tasks while seeing patients are more likely to have errors in paperwork and not be up to date on changes and updates to payer processes.

Insider Advice: You may overpay for prior authorizations by assigning highly skilled nurses to complete these tasks in-house. Outsourcing this role to a vendor offering a la carte services, one who customizes their solutions to best fit your needs, will result in streamlined costs while improving approvals and faster payments.

Improved Cash Flow

Faster prior authorization approvals accelerate the billing and reimbursement process, leading to improved cash flow for the practice. Cash flow will also continue to accelerate as your internal staff increases their ability to treat patients.

Insider Advice: Find a vendor that bills a flat hourly rate instead of a percentage of authorization approvals; the former will allow you to forecast these expenses and maximize revenue. A reputable vendor billing hourly should also hold regular accountability meetings, ensuring a successful partnership.

Enhanced Patient Satisfaction and Care

When the prior authorization process becomes streamlined, delays in care decrease, practices deliver enhanced patient satisfaction, and retention improves. Patients are more likely to continue seeking care from practices that provide timely and efficient services, leading to increased loyalty and word-of-mouth referrals.

Outsourcing prior authorizations is a strategic opportunity for healthcare practices looking to increase patient retention and profitability. Finding a dependable vendor enables the practice and vendor to work towards reducing administrative burdens, improving patient care, and enhancing overall practice performance in today’s healthcare landscape.

Sources:

American Medical Association, 2023 AMA Prior Authorization Physician Survey.

American Medical Association, “9 States Pass Bills to Fix Prior Authorization”, by Tanya Albert Henry, March 8, 2024.