The following is a guest article by Dr. Steve Kim, Co-Founder and CEO at Valer
Prior authorization automation is an essential consideration for healthcare organizations seeking to streamline their processes in the coming year. Automating prior authorization workflow offers several operational, financial, and clinical benefits, including fewer avoidable denials, procedure cancellations, and delays in care, better patient outcomes, improved staff productivity, and more.
If you’re considering adopting prior authorization automation technology for the first time, or you’re potentially switching from an existing provider that’s falling short, here are three things to know to help get the most from your investment.
Know Your Core Challenges
Before implementing prior authorization automation, the most crucial step is to understand the core challenges your organization faces with current processes. If your organization is new to the idea of automating your prior authorizations, you’re likely dealing with pain points stemming from a highly manual, repetitive process. These can materialize in three major ways.
According to a survey by the American Medical Association (AMA), 80% of physicians report that the complexity of prior authorization processes has increased over the past five years. For organizations with manual prior auth processes, this means having to expend time and resources to adapt to evolving regulations and ensure compliance. This places an undue burden on healthcare professionals and can lead to high levels of burnout.
Next, you have the core challenge of administrative burden. A separate study published in the AMA found that administrative tasks, including prior authorization, account for nearly two business days of physician and staff time per week. This is valuable time that could be spent directly interfacing with patients. Recognizing the extent of this burden within your organization will underscore the potential impact of automation in terms of time and cost savings.
Finally, consider any communication challenges your staff is experiencing due to inefficient prior auth processes. NAHAM’s 2023 Prior Authorization Survey highlights that 65% of respondents think initial denials are often approved following appeal and/or peer-to-peer meetings. In manual prior authorization processes, there’s a lot of room for error and communication breakdown. While many physicians see success in appealing decisions, that exercise is a drain on time and resources and delays necessary patient care. Addressing these gaps by leveraging automation can enhance collaboration between healthcare providers, payers, and patients, leading to a more streamlined and transparent authorization workflow.
Know Your Automation Options
Once you clearly understand your organization’s challenges, the next step is to explore your prior authorization automation options. Not all solutions are created equal, and finding the right fit for your organization requires careful consideration.
First, let’s look at artificial intelligence (AI). A recent report suggests that 65% of physicians see an advantage to using AI, particularly in helping to reduce administrative burdens, including documentation and prior authorization. That said, it’s important to note that automation (like AI bots) purely to determine when a prior authorization is required often falls short of replacing the costliest and most time-consuming work. For effective automation, you need solutions that can do more than scrape payer websites to determine if prior authorization is necessary and if they can get past website multi-factor authentication.
Beyond AI, you should understand the integration capabilities you need when selecting any healthcare IT solution. Seamless integrations with existing systems and workflows, including EHRs and practice management platforms, are crucial for maximizing the benefits of automation and minimizing disruptions to your organization.
Lastly, consider customization and scalability when researching automation options. Many prior authorization solutions require a complete overhaul of your existing workflows. While they might be effective, they’re disruptive and add additional burden to your staff. Automation solutions tailored to your current processes and grow with your organization are more seamless to integrate and operate long-term.
Know the Features Your Organization Needs for Success
Implementing prior authorization automation is not just about choosing technology; it’s about selecting a tool that aligns with your organization’s specific needs and goals. Here are key features to consider when evaluating automation options.
Automated Submission Capabilities
Your prior authorization automation solution should streamline the process of submitting data, documentation, attachments, and notes, effectively eliminating manual redundancies and reducing the likelihood of errors. True automation like this leads to less staff time for submissions, greater staff productivity, extensions in authorized days out, and reduced processing time.
Real-Time Eligibility Verification
Real-time eligibility verification driven by bi-directional data integration is another critical feature. Offered by advanced automation solutions, it mitigates delays in patient care, allowing healthcare providers to confirm patient coverage instantly and initiate the authorization process promptly. Real-time verification functionality also gives your staff the ultimate visibility into processes to reduce errors, duplicative work, and denials associated with manual authorization workflows.
Analytics and Reporting
Lastly, consider a unified platform and portal with robust reporting functionality in your automation solution. A single platform encompasses all payers, care settings, service types, and specialties. This consolidation minimizes the complexity of navigating diverse payer processes. When you layer comprehensive analytics and reporting tools on top of that platform, you gain insights into staff productivity and payer performance, enabling data-driven decision-making.
A Streamlined, Simplified Year Ahead
Implementing prior authorization automation in 2024 requires a strategic approach. By understanding your core challenges, exploring automation options, and prioritizing the features essential to your practice, you can pave the way for staff productivity and patient health outcomes.
About Dr. Steve Kim
As Co-Founder and CEO, Dr. Kim leads Valer’s overall mission and strategy. With more than 20 years of medical experience and a passion for studying value-based care outcomes, Dr. Kim’s expertise has been vital in navigating the evolving complexities of the healthcare industry and identifying the administrative roadblocks and bottlenecks delaying access to care. Before his transition into business entrepreneurship, Dr. Kim was an Assistant Professor of Urology at the University of Southern California’s Keck School of Medicine, where he served as the Director of Clinical Research Informatics for Children’s Hospital Los Angeles in addition to practicing pediatric urology.
