Summer 2024 Issue

Navigating Prior Authorization
By John Garcia
For The Record
Vol. 36 No. 3 P. 14

How to Increase Efficiency With Automation

If you’ve ever walked into the doctor’s office for an appointment, chances are your physician, at some point, has recommended a service or treatment. This could be something as mundane as a change in your prescription or something much more consequential, such as a treatment or procedure.

Since the 1960s, a process known as prior authorization (PA) has been used by insurance companies to authorize these services—treatments, drugs, procedures, surgeries, and more. Insurance companies establish workflows to regulate what procedures are performed, creating governance to serve as a set of guardrails for physicians.

In recent years, PA has garnered increased attention. Initially targeting high-cost care like cancer treatment, insurers now frequently demand PA for routine medical procedures, such as basic imaging and prescription refills. According to a 2021 survey by the American Medical Association (AMA), 40% of physicians reported having staff members dedicated solely to handling PAs.1

How Does PA Affect Care Delivery?
PA at its core was introduced to help control costs. Unfortunately, in more cases than not, PA has become a barrier to care and has caused administrative costs and burdens to rise.

On the commercial payer side, a 2021 poll by the Medical Group Management Association2 found health care leaders needed to add full-time positions to handle the massive burden of PA and avoid frustrations including the following:

• inconsistencies across payers on authorization requirements;
• frequent updates in payer requirements;
• vague or opaque requirements;
• increasing denials and requirements
for peer-to-peer reviews; and
• slow responses from payers.

On the government-entity side, CMS has a specialized set of guidelines and rules for Medicare and Medicaid programs. Providers are placed in a difficult position of having to navigate not only the commercial payer guardrails but also the CMS rules,3 adding to administrative burden and delay in care.

In a survey conducted by the AMA in 2022, 88% of the physicians reported that the burden associated with PA is high or extremely high.4 Care is either being severely delayed to the point of adverse care events or patients are abandoning treatment/necessary procedures altogether. Further, the study found the following:

• 33% of physicians reported PA leading to a serious adverse event for a patient in their care;

• 25% reported PA led to a patient’s hospitalization;

• 19% reported that PA led to a life-threatening event or required intervention to prevent permanent impairment or damage; and

• 9% reported PA led to a patient’s disability/permanent bodily damage, congenital anomaly/birth defect, or death.

What’s Being Done to Solve the Problem?
Given the growing frustration due to delays in care as a result of the PA headwinds, CMS has taken measures into its own hands, which ultimately will save physician practices more than $15 billion in the next 10 years. The changes announced earlier this year apply to government-regulated plans, such as Medicare Advantage, Medicaid, Children’s Health Insurance Programs, fee-for-service programs, Medicaid managed care plans, and all other health plans on federally dictated exchanges. The changes include the following:

1. Requirement for payers to make PA decisions within three days or 72 hours for urgent requests, and seven days for nonurgent requests. As CMS states, “For some payers, this new timeframe for standard requests cuts current decision times in half.”

2. Requirement for payers to support electronic PA that is embedded in the EHR, bringing a new level of automation and efficiency to an outdated and currently inefficient workstream.

3. Requirement for payers to share information on the reason for denials and publicly report these metrics, answering common questions such as: How often do you approve authorization requests? How often do you deny them? How long is the process for said authorization?

The hope is that the proposed changes outlined previously will extend to commercial payers as well and increase access to care delivery, reducing the long-term negative consequences for patients. Additionally, there’s optimism that these changes will help health systems spend less time investing resources—time and money—into PA-related tasks.

Payer-Provider Relationship
If payers live on Jupiter, then providers live on Mars. Unfortunately, the bridge between these two entities is long. As an industry, we collectively need to do a better job of working together for the sake of care delivery and better patient outcomes.

The main reason for the divide is lack of payer transparency and clarity given to providers. This is true for what’s required up front as well as the reason for the denial if the authorization is not approved.

Three major components that are essential to payers, summarized by the California Health Benefits Review Program, 5 are medical necessity, safety and appropriateness, and cost control. Payers are adamant about points of entry—incorrect or missing information on the authorization form, policy coverage exclusions, and misrepresentation or false information about preexisting conditions—which can lead to hang-ups on the provider side. However, thanks to automation, these upfront pieces of documentation can be simplified for efficiency and timeliness.

In addition to lack of transparency, providers are often faced with navigating the aforementioned workflows that vary widely across different service lines and payers. It takes a lot of time for a revenue cycle worker to learn these intricacies and how to navigate them. And unfortunately for providers, the rules can change abruptly with no foresight from the payer.

Finally, there are challenges with peer-to-peer review. This process begins after the authorization is denied, and the ordering physician has disagreed with the decision. The ordering physician and a physician from the payer can arrange a meeting with the goal of explaining the rationale to support the order and obtaining PA for the procedure, prescription, or other service that they intend to order, ultimately appealing a previously denied PA.

The “peer” from the payer side, who knows virtually nothing about the service in question, usually comes from a completely different specialty. Going forward, AMA recommends peer-to-peer meetings that take place immediately following an adverse PA determination.6 Furthermore, the “peer” should be a doctor who practices in the same specialty and state as the ordering physician.

Unfortunately, all of these components—the upfront paperwork, the back and forth with the payer portals, and the peer-to-peer review process—often take days or even weeks to navigate. This contributes to high denial rates, which affect everything from delayed care to number of days cash on hand for providers.

Where Does Automation Come Into Play?
The ongoing labor shortage remains a big issue, prompting teams to explore workflow automation to resolve staffing challenges. Automation can be a worthwhile investment for PA, making the process less taxing on both providers and patients. However, it does require a good amount of legwork to navigate the ebbs and flows of the current market.

By resolving root causes of issues, such as cumbersome payer expectations and the reasons for denials, payers and providers should be able to find common ground that ultimately benefits the patient. While there’s no perfect solution, automation has come a long way to help hospitals take back autonomy in the PA process, particularly pertaining to write-off improvement and time savings. Whether you’re looking to handle it inhouse or bring in a trusted vendor partner to help with your organization’s PA journey, consider the benefits of automation as a tool to advance to the next level.

Here are five recommendations to support the process of automating PA workflows.

1. Understand your current resources. Before you can automate anything, you must know where you’re spending the most time and money in the process. Automation for automation’s sake is a wasted commodity, so take the time to fully assess where your team is thriving and where they need help.

Managing people, processes, and technology is a full-time job. And each EHR platform treats individual payer connections as a unique standalone, meaning your team has to manage the daily blocking and tackling that comes with each of these integrations. If this burden becomes too much to bear inhouse, it’s time to consider support from outside resources.

2. Know that “free” is not always better. Beware of free PA services that seem attractive but in reality add to the complexities already surrounding PA. Many are payer-driven services, meaning they are tailored to the preferences of the large, national payers that may fail to align with your organization’s specific needs and workflows. Other red flags to watch for with “free” PA services include fragmented workflows, omission of the exclusion of government and managed payers, and hidden fees that take the form of manual processes.

3. Determine your payer mix. This includes Cigna, Blue Cross, Humana, and more. There are a lot of payers out there, and depending on the hospital or health system, your team could be interacting with many of them on a given day. It is important to know how much time your patient financial service reps are logging in and navigating the various payer portals each day to check the status of a PA, submit additional documentation, or appeal denials. According to AMA, practices average 45 PAs per physician per week.4 This is an average of 14 hours a week, or two business days, on PA. Consider what else you could do with 14 hours in your week.

4. Look outside your EHR. You’ve invested hundreds of thousands of dollars along with considerable effort to implement your organization’s EHR. Now it’s important to look outside the EHR. While many EHRs deal with large, national payers, they don’t always have a great pulse on local/regional payers and specialty areas, such as cardiology or surgery. These specialized areas require unique attention that extends beyond your EHR partner’s capabilities.

In these scenarios, it’s worth looking into other options to supplement. Strategic automations keep your team in the driver’s seat, being mindful that overautomation and removing people from workflows is not the way to go. And, having a centralized connection source (your EHR) along with outside PA support can help manage resources more efficiently while taking a more strategic approach to managing revenue cycle initiatives at your organization.

5. Determine what you are trying to solve. It’s important to know the areas that need improvement and the resources you have at your disposal. While the negative effects of PA on the patient experience are devastating, they are also very much avoidable.

One example of this: According to the 2022 Optum Revenue Cycle Denial Index, nearly one-half of all denials start in the front-end of the revenue cycle.7 Furthermore, 13% of denials that could otherwise have been avoidable are due to authorization and precertification issues. If the bulk of your PAs are being denied, automation offers a solution to eliminate human errors that lead to denials in the first place, ultimately resulting in write-off improvement.

Use Case: How Carle Health Automated PA
Background: Carle Health, a vertically integrated system based in Urbana, Illinois, has 16,800 employees in its hospitals, multispecialty physician groups, and associated health care businesses. Common frustrations included navigating payer requirements, submitting authorizations, and tracking approvals. These administrative burdens, while crucial, were draining valuable time and resources from the Carle Health patient financial service team, which could be reallocated, making a PA solution to simplify workflows a necessity.

Solution: Carle Health, an Epic shop, decided to bring in a partner with a strong track record of integration with their existing EHR. The goals of reducing administrative workload and enhancing efficiency were quickly met thanks to this partner’s attention to detail and coverage for more than 80% of Carle’s commercial and managed care payer mix. Additionally, the partnership allowed for support of five service lines, including radiology, cardiology, orthopedics, general surgery, and GI. Through automation, Carle was able to save 10 minutes across the end-to-end PA workflow, equaling thousands of hours of work given back to their teams. This enables Carle to pivot resources to higher priority tasks while removing tedious work from employees’ responsibilities.

Parting Thoughts for Getting Started
The concept of tackling PA at your organization, particularly when it comes to automating workflows, can be daunting. Take it one day at a time, one payer at a time, and the results will come. If you are considering bringing in a third party to help with PA, particularly outside of the sources available to you within your EHR, here are some closing thoughts.

First, be transparent and request transparency. What issues are keeping you up at night? What level of detail are you not seeing in your current setup that could help you increase efficiencies? For example, having visuals such as screenshots that demonstrate approvals, denials, rationale for denials, and next steps is an effective way to see what processes can be improved and which areas of the workflow have the most bottleneck. Ask your potential vendor partner about payer and service line coverage. No information should be off the table in the early conversations.

Second, strive for accuracy. Junk in equals junk out, especially when automation is concerned. Remember, the goal is not to get rid of people all together, but rather to have people own what makes the most sense for them to control, and automate the menial tasks that take them away from more strategic priorities. It’s true that the less manual entry and staff needed to work on a given authorization, the cleaner and more accurate your claims will be—meaning fewer write-offs and rework on the back end.

Last, but not least, seek stability. There are many automation companies, but not all are familiar with the intricacies of revenue cycle. It’s important to know the difference and ask detailed questions about their skillsets. It’s also imperative to ask if a prospective partner integrates seamlessly into the EHR. What connections do they leverage for integrations, and are they stable? Finally, don’t be afraid to ask for references and metrics that support success rates. Find other organizations that have worked with the potential vendor partner. Your goal should be to share information as securely and efficiently as possible with your payer mix so that downtime is minimized, and you’re adding more hours back into your team’s day.

— John Garcia, chief product officer of Janus Health, is a skilled product management leader in health care technology with extensive experience leading product development teams to develop market-leading revenue cycle management solutions. He’s worked in the industry for more than 20 years, guiding and excelling in project management, operations, sales, and account management. At Janus, he works to expand solutions to provide new enhancements and untapped service lines—from automation capabilities to improved workflow.

 

References
1. Most physicians had little relief from prior authorization as COVID cases soared. American Medical Association website. https://www.ama-assn.org/press-center/press-releases/most-physicians-had-little-relief-prior-authorization-covid-cases. Published April 7, 2021. Accessed May 7, 2024.

2. Ernst C. Prior authorization burdens for healthcare providers still growing during COVID-19 pandemic. Medical Group Management Association website. https://www.mgma.com/mgma-stats/prior-authorization-burdens-for-healthcare-providers-still-growing-during-covid-19-pandemic. Published May 19, 2021. Accessed May 7, 2024.

3. CMS finalizes rule to expand access to health information and improve the prior authorization process. Centers for Medicare & Medicaid Services website. https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process#:~:text=For%20some%20payers
%2C%20this%20new,or%20an%20appeal%20when%20needed. Published January 17, 2024. Accessed May 7, 2024.

4. American Medical Association. 2022 AMA prior authorization physician survey. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf. Published 2024. Accessed May 7, 2024.

5. California Health Benefits Review Program. Prior authorization in California. https://www.chbrp.org/sites/default/files/bill-documents/Prior%20Authorization_final.pdf. Published 2023. Accessed May 7, 2024

6. O’Reilly KB. 7 prior authorization terms that drive every doctor to distraction. American Medical Association website. https://www.ama-assn.org/practice-management/prior-authorization/7-prior-authorization-terms-drive-every-doctor-distraction#:~:text=to%2Dpeer%20review-,Peer%2Dto%2Dpeer%20review,appeal%20a%20previously%20denied%20PA. Published November 13, 2023. Accessed May 7, 2024.

7. The Optum 2022 revenue cycles denials index. Change Healthcare website. https://www.changehealthcare.com/insights/denials-index. Published 2022. Accessed May 7, 2024.