Prior authorization is an unavoidable process in cardiology practice that has proven frustrating. While it tries to control healthcare costs and stop unnecessary treatments, it usually results in delays. It disrupts patient care and is accompanied by an enormous administrative burden. It usually involves complex and expensive procedures, so effective navigation through those challenges is inevitable for the cardiology practice.
In this article, we will examine standard cardiology practices where prior authorization is a barrier and investigate strategies for efficient streamlining that reduce denials and generally maximize the system’s effectiveness.
Common Challenges in Prior Authorization for Cardiology
- Delayed Patient Care
One of the most serious disadvantages of preauthorization is that it delays diagnosing and treating patients. Many cardiology procedures, such as stress tests, echocardiograms, and cardiac catheterizations, must be authorized before being performed. At times, approval takes days up to a week, which can be an essential time gap in treatment for most patients suffering from heart conditions.
Example:
A patient with acute chest pain needs an urgent angiogram, and a delay due to prior authorization may worsen the condition and may result in serious complications or hospitalization.
Solution: An efficient workflow can be adopted by prioritizing urgent cases and communicating proactively with insurance providers to expedite approvals.
- Increased Administrative Burden
Hours are spent completing and submitting paperwork, and payers’ responses are awaiting. Payer makes things even more confusing because of prior authorization, requiring employees to familiarize themselves with so many different policies.
Impacts of the Practice
- Inefficiency occurs due to losing staff time engaged in paperwork rather than treating the patients
- There is a higher likelihood of errors being committed and submissions being missed by payers.
Solution: Leverage EPA systems integrated with EHRs to make submitting and tracking in real-time more manageable.
- Lack of Standardization Between Insurers
All insurance companies’ different rules, requirements, and due dates pertain to their authorization process. Most likely, these might be too huge and overwhelming differences for practices with respect to allowance and denial variations.
Solution: Develop a list of payer criteria for standard cardiac procedures. To keep track, specific officers could be assigned to updates and changes made in different policies to ensure they are knowledgeable about each type of requirement each insurer has set.
Overcoming Prior Authorization Challenges in Cardiology
- Leverage Automated Prior Authorization Solutions
Technology can significantly alleviate the burden of prior authorization. Automated solutions can :
- Verify coverage in real-time.
- Determine potential authorization requirements well before treatment.
- Shrink the mountain of paperwork and increase approval rates
- Many EHR systems now offer built-in prior authorization tools that integrate with payers, making the processing faster and more efficient.
- Collect Documentation Proactively
Most authorization requests are denied because the supporting information is incomplete or incorrectly prepared. Therefore, it is essential to ensure that all relevant medical records, test results, and physician notes are included with every request.
Best Practices:
– Use checklists to verify proper documentation that is attached to every request
– Educate staff on requirements for each payer
– Conduct audits periodically to determine where errors in documentation are happening to implement corrections
- Developing Relationships with Payers
Building good relationships with insurance representatives can expedite approvals and provide insight into changing policies. Regular communication with payers will help resolve issues quickly and negotiate favorable terms.
Pro Tip: Establish a single point of contact within your practice to maintain communication regarding insurance and monitor policy changes.
- Patient Communication Should be Kept as a Top Priority
This delays typically the patient’s treatment due to prior authorization. By educating the patient on the process and the time it takes to complete it, this anxiety is reduced, and patients will be satisfied with the services offered.
How to Improve Communication:
- Explain the process of prior authorization at the first visit.
- Give the patient a timeline and update him regarding the process.
- Provide alternative treatment options if a delay occurs in seeking approval.
- Outsource Management of Prior Authorization
For many cardiology practices, outsourcing prior authorization to a specialized medical billing service can significantly reduce workload and increase efficiency. These services have experienced professionals handling submissions, follow-ups, and appeals, freeing in-house staff to focus on patient care.
Benefits of Outsourcing:
– Faster approvals and fewer denials.
– Reduced administrative burden.
– Increased revenue cycle efficiency.
Optimizing Prior Authorization for Better Patient Care
Prior authorization is necessary but often cumbersome in cardiology practices. Delays, administrative burdens, and high denial rates create significant challenges that impact patient outcomes and practice revenue. However, cardiology practices can more effectively navigate these hurdles by implementing automation, improving documentation practices, strengthening payer relationships, and considering outsourcing.
Streamlining prior authorization would make operations smooth and facilitate timely and required cardiac care to the patients. With increased awareness and the proper implementation of best practices, cardiology practice can reduce the impact of prior authorization and enable them to carry on the work with the high-quality service provided to their patients.
