If you’re a provider’s office, chances are you’re likely all too familiar with prior authorization (PA) requests. These requests are made to insurance payers to obtain authorization for healthcare services and to ensure that the insurance payer will accept billing for those services. The theory behind the creation of this was to conserve resources and protect against frivolous insurance usage. However, needing such a higher number of authorizations has created a bottleneck that severely slowed down the speed of patient care.
The Prior Authorization Problem
Based on an average of over 1,000 healthcare providers, restricted access to care because of prior authorizations can have severe long-term negative consequences. Waiting on prior authorizations leads to hospitalization 25% of the time, life-threatening events 19% of the time, and permanent damage (including death and disability) 9% of the time. Even worse, getting prior authorizations denied can draw out this process even longer.
It is estimated that 27% of physicians believe their prior authorizations are almost always denied, and 35% say the prior authorization criteria are scarcely evidence-based. Worst of all, 3 out of 4 doctors believe the number of denials has increased by some extent in the past 5 years. All this means that patients will have to wait even longer for proper treatment, potentially jeopardizing their health. In fact, around half of physicians believe their patients’ health simply cannot wait for approvals. So, what is it about the prior authorization process that makes it so time-consuming and highly denied by insurance companies?
The Manual Prior Authorization Process
The process of manual prior authorizations usually comes in around 6 steps. Firstly, a member of the administrative staff must manually check the patient’s insurance details to determine if prior authorization is a necessity for the planned procedure. This can be done either by calling the patient’s insurance company or by logging into online portals. Next, the patient’s medical charts must be assessed to see if they fit the guidelines for the given prior authorization. Then, the PA request is submitted via Fax or insurance portal, which can take anywhere from 15-20 minutes per patient.
Once the PA request itself has been sent, the job isn’t finished. Someone from the healthcare provider’s office needs to follow up on the request, either by phone call, email, or logging into the insurance company’s portal. Then, if the request is denied, this whole process must start all over again, including appeal documentation. When the request is finally approved, the healthcare provider’s office must update the medical records to reflect that before rendering any treatment.
The Impact of Manual Prior Authorizations
As you can imagine, this puts an incredible administrative burden on a healthcare providers’ office, especially one that is smaller in scale. A whopping 93% of physicians say prior authorizations leave them with a ‘high’ or ‘extremely high’ administrative burden. It equates to around $11, and 20 minutes wasted for every single PA for every patient. For this reason, 35% of healthcare providers hire staff to work on prior authorizations alone. Fortunately, modern technology has shown there is a better way to get prior authorizations done.
The Solution: AI-Powered Automation
With AI-powered prior authorization process automation, a whopping 82% of the prior authorization process can be fully automated. Rather than having to get all the patient documents, these automated systems retrieve the data and voice call insurance companies to see if PA is required for the intended procedure. Then, the AI reviews the patient’s medical records to validate that the patient fits the prior authorization guidelines. Next, the automated system enters the insurance company’s portal completes the prior authorization request and automatically monitors the submission status intermittently. If the request is approved, the AI will even update the patient’s medical records so your provider’s office doesn’t have to.
The Benefits of automation
The benefits of automated PA workflow systems speak for themselves. Orbit AI, for example, has been shown to save 60% of all existing provider costs and around $449M across the entire U.S. medical industry. Moreover, with automated systems, the time to complete a PA goes down to under 5 minutes and the cost is reduced by around $9.60. Most importantly, it frees up around 12 hours per staff member, per week, which allows your staff to get back to helping your patients. Regardless of what your provider’s office provides your patients, using AI-powered prior authorization systems makes it easier for you to get back to helping patients.
