Prior authorization is an essential but too vexing element of health care delivery. Managing prior authorization requirements can be especially challenging for multispecialty health organizations that provide a range of services in one location.
With multiple insurance carriers, different policies, and complicated documentation requirements, the process can result in delayed treatment, administrative inconvenience, and even lost revenue.
We will explore how multispecialty health groups can manage prior authorization requirements effectively, streamline workflows, and ensure timely patient care.
What is Prior Authorization?
Prior authorization is when healthcare providers must obtain prior approval from a patient’s insurance company before delivering certain treatments, procedures, or medications. This step ensures that the service is medically necessary and covered under the patient’s plan.
Although prior authorization is meant to manage costs and avoid unnecessary care, it creates administrative barriers for providers and delays patient care. The complexity is compounded for multidisciplinary health groups that provide varied services such as cardiology, orthopedics, and dermatology.
Problems of Prior Authorization in Multispecialty Health Groups
- Varied Insurance Needs
Every insurance company also has its own prior authorization requirements, such as particular forms, documentation, and time frames. For multispecialty groups, it can be confusing to consider all these differences across specialties.
- Time Consuming Processes
Prior authorization is normally a multi-step process, from entering patient information to claims processing and follow-up calls with the insurers. It may take days or hours, taking staff away from patient care.
- Delayed Denials
Inaccurate or incomplete submissions will result in claims denials, which must be resubmitted and further postpone patient care. These delays are critical for patients in urgent need.
- Administrative Burnout
The sheer number of prior authorization requests can overwhelm administrative staff, leading to burnout and more opportunities for errors.
Strategies for Streamlining Prior Authorization in Multispecialty Health Groups
- Centralize Prior Authorization Processes
Multispecialty practice groups have the option of streamlining their prior authorization process. Consolidating these procedures allows a single department or team to carry them out more easily, resulting in consistency where there used to be chaos, more errors, and less efficiency.
These are the needs of each carrier or specialty to be able to push through the system efficiently.
- Use Technology and Automation
Investment in prior authorization software will yield returns in the form of process automation. The software can:
- Automate request filing
- Monitor request status in real-time
- Detect incomplete or incorrect submissions
- Interface with electronic health records (EHR) to pull patient data effortlessly
Automation not only speeds up the process but also reduces the likelihood of human error.
- Standardize Documentation Across Specialties
Standardized templates for prior authorization requests can be useful. They can be designed for different specialties and carriers and cover all that is needed.
A cardiology prior authorization form may have individual boxes for diagnostic test information, while an orthopedic one would concentrate on imaging studies and treatment plans.
- Educate Staff on Insurance Policies
Regular clinical and administrative staff training can familiarize them with newer insurance schemes and prior authorization protocols. This information empowers the staff to forecast possible obstacles and minimize the denial rate.
- Develop Strong Payer Relationships
Open communication with payers can facilitate the prior authorization process. Multispecialty health organizations must have a point of contact for every major payer to resolve issues and clarify requirements quickly.
- Track and Analyze Denial Rates
Monitoring previous denials for prior authorization can also be of great value in determining typical problems and areas for improvement. Denials that have been worked on can help practices recognize repeated errors, like inadequate documentation or coding errors, and modify accordingly.
- Educate Patients on Prior Authorization
Patients are generally frustrated by delays resulting from prior authorization. Informing them about the process and giving them realistic expectations can enhance patient satisfaction and decrease anxiety.
For instance, staff can inform patients about the standard processing time for approvals and the status of their requests.
Where to Outsource Prior Authorization – Does It Make Business Sense?
Some multispecialty medical groups could benefit from outsourcing prior authorization functions to a medical billing service company specializing in this activity. These companies have the expertise and capacity to handle bulk authorization requests more efficiently, offloading the administrative burden from in-house employees.
Outsourcing ensures that the orders are completed by specialists knowledgeable in the prevailing insurance policies and procedures, limiting the risk of denials and delays.
Impact of Effective Prior Authorization on Patient Care
Simplifying prior authorization procedures isn’t just in the best interests of healthcare providers—patient care also benefits. With reduced lag time, multispecialty healthcare organizations can help ensure patients have immediate access to necessary treatment.
For instance, an MRI may be initiated earlier in a patient requiring an MRI because of an alleged injury. Likewise, a cancer patient might be administered chemotherapy on schedule, thereby encouraging their recovery opportunity.
Pre-approval is a complicated but unavoidable part of healthcare delivery, particularly for multispecialty health organizations. By streamlining processes, using technology, and investing in employee training, organizations are more likely to manage insurance requirements and lower administrative costs.
Effective prior authorization processes result in quicker approvals, enhanced patient outcomes, and a healthier bottom line. For multispecialty health groups seeking to maximize their performance, the science of prior authorization is one step closer to victory.
