Client
A conglomerate of medical practices specializing in various fields, based in North Carolina, catering to a sizable patient population, aimed to enhance the efficiency of their Prior Authorization process.
Challenges
The group was facing several issues with their prior authorization process due to lower rate of approval of Prior Authorization requests and long duration to complete the whole process. The inefficiencies in PA process, in turn, resulted in increasing trends in claims denial due to PA and decreasing number of patients for delayed medical treatment.
To address those issues, the group decided to streamline their prior authorization process with two primary objectives – (a) improve approval rate of prior authorization requests and (b) reduce time to obtain PA approval.
Our Approach & Solutions
We conducted an in-depth analysis of historical data concerning prior authorization (PA) requests and their approvals, aiming to discern prevalent trends. Our approach involved categorizing the data by payer and specialty, dissecting reasons for PA denials, and assessing the average time required for PA approval. Additionally, we pinpointed the payers associated with a higher frequency of denials, enabling us to prioritize our strategic actions effectively.
Our adept prior authorization team diligently orchestrated and implemented task-specific procedures tailored to individual payer guidelines and criteria. To streamline our operations and enhance efficiency, we strategically emphasized the collection of essential supporting documents crucial for establishing medical necessity, a pivotal factor in PA denials. Furthermore, we aimed to submit PA requests promptly with comprehensive documentation within the same day. Our team rigorously monitored and persistently engaged with the utilization management teams of respective payers until successful resolution. In instances of denials, we meticulously adhered to the appeal management process to seek a re-evaluation of our PA requests.
Results
With meticulous, prompt and diligent effort, our teams successfully achieved the target within three months from the start of prior authorization operations and improved authorization approval rate and faster turnaround time.
The improvement in prior authorization resulted in improved efficiency of the billing process. reduced claims denial rate due to prior authorization and improved reimbursements.
- PA approval rate increased by 30%
- Average time taken has improved to 3-4 days from 6-7 days earlier
- Reduced denials due to prior authorization
- Operational cost for the PA team reduced by more than 60%
