Prior Authorizations’ Impact on Healthcare

A survey conducted by the American Medical Association (AMA) discussed the impact of prior authorizations on patient care. Out of a sampling of 1,000 physicians, one-third of the respondents stated they have a dedicated staff who work on prior authorizations approximately two business days, or 14 hours, each week with 86% of the physicians surveyed ranking the prior authorization burden as being extremely high.

Unsurprisingly, 90% of physicians surveyed also stated that for those patients requiring a prior authorization for treatment, the process impacted clinical outcomes. Care was delayed in 43% of the cases sampled.

The Centers for Medicare & Medicaid Services (CMS) finalized a rule as part of their “Patients over Paperwork” initiative, which began in 2020. This final rule builds on the efforts to drive interoperability and reduce costs in healthcare by promoting secure electronic access to health data. This includes changes like allowing payers, providers, and patients to have electronic access to pending and active prior authorization decisions, in the hope it will result in fewer repeat requests for prior authorizations.

But, it’s not relieving hospitals, health systems, and providers of the present burden, forcing most to use a tedious and inefficient referral authorization process that navigates disparate portals with varying requirements for revenue cycle operations.

The workflow is clunky, error-prone, and mostly manual. When corrections are necessary, this loop of information gathering has to be repeated, adding another layer of complexity to what should be a simple process.

This manual process can take as many as forty-five clicks on various screens. The prior authorization need will always be there, but the complexity of steps that need to be taken is removed altogether through use of RPA. Automation searches for the treatment, applies the necessary codes, corrects inaccuracies or missing information, sends it to the payer, and lets staff know if the treatment needs further clarification. The process becomes nearly seamless and requires no manual intervention.

Boston Software Systems’ workflow automation platform enables revenue cycle managers to complete routine jobs efficiently and with 100% accuracy. In addition, claims status automation presents a big opportunity for both providers and payers to save money. It is estimated that the industry could save an average of $9.22 per claim status inquiry by eliminating manual processes. Costly, labor-intensive, error-prone tasks are exactly where automation shines, transforming the business of healthcare and eliminating waste from the system.

Brad Cox, Director of Patient Accounting at Northwestern Medicine states, “We found that we could automate any part of a process. We completely automated the Medically Unlikely Edits (MUE) process. We’re able to work an additional 4-6 denials every day. We look forward to automating this entire process, having the system do the write-off or adjustment for us, rather than having a person touch any part of the denial process.”

COVID-19 created a cash flow slowdown for providers. Since the start of the pandemic, hospitals and health systems have worked tirelessly to sustain revenue cycle operations amid fluctuating patient volumes. According to a recent study by Kauffman Hall, total expenses for hospitals jumped by 2.6% in February 2021, compared with the same month in 2020. Revenue cycle integrity and speed are paramount to operational sustainability.

Why Boston Software Systems?

At Boston Software Systems, we work with all revenue cycle systems, driving increased profitability and increasing staff productivity. Give us a call, we won’t take up much of your time. With most solutions implemented in < 45 days, improved efficiencies and reduced costs are right around the corner.

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