A Guide to Improving Your Prior Authorization Process

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You’ve analyzed your operations, streamlined workflow and trained your staff, yet your revenue doesn’t match the number of physicians or the patient treatment hours they log. What is going on? Where are the revenue leaks and losses you can’t put your finger on? The culprit is usually a prior authorization process that looks like a bit like Swiss cheese. You can close those holes with electronic prior authorization and in the process resolve many of your revenue headaches. Here’s a brief guide to help you identify some of the gaps that may be leaking revenue in your practice.


How to Manage Your Prior Authorizations


The fact is that prior authorization is the bane of every physician’s existence. New prior authorization regulations continue to roll downhill and managing them is the only way to survive. In 2017, 86% of medical practice leaders said their prior authorization requirements had increased over the past year.

Physicians across the country feel the prior authorization pain. Of one thousand physicians surveyed:

  • 75% believe that prior authorization places “high or extremely high” burdens on them and their staff.
  • 41% spend up to 20 hours each week on prior authorization tasks
  • 90% report that prior authorization causes delays in the delivery of necessary care

Those are big headaches and significant obstacles to the timely delivery of patient care.


Optimize and Maximize


The only way to survive onerous prior authorization burdens is to optimize performance and maximize revenue through electronic prior authorization. Best practices in prior authorization are built on software that delivers the following benefits:

  • Timely preauthorizations conducted at the time of patient scheduling
  • Accurate preauthorization details obtained for accurate claims
  • Preauthorization tasks are automated, reducing physician admin time
  • Cloud-based tools automate preauthorizations and streamline workflow

When you optimize the amount of information you have and maximize its timeliness, the result is more accurate claims and fewer denials. That equals more revenue. To judge the effectiveness of your current prior authorization processes, look at your claims.

  • How many are successful?
  • How many are denied?
  • Are you able to appeal denials within the payors window of time?
  • What is your aging Accounts Receivable (A/R)?
  • Is the A/R growing and do you know what is in it?

You can employ medical tactics in your office to address each of these issues. You can turn revenue obstacles into revenue opportunities but only to the extent that prior authorization processes are managed and optimized.


Speed and Accuracy


Speed and accuracy is the name of the game when it comes to prior authorization processes. Without it staff doesn’t know if specific patient care is approved, physicians don’t have the information they need to schedule care, and delivery is unnecessarily delayed. Electronic prior authorization automates the process according to the patient and the treatment at hand. For example, the best software delivers:

  • 24-hour turnaround for standard prior authorization needs
  • 2-hour turnaround for emerging patient needs
  • 20-minute turnaround for STAT scheduling and treatment

Ask yourself the following questions:

  • Do you know your capability to authorize treatments within these time frames?
  • Are delays impeding cash flow?
  • Are patients going elsewhere for timely treatment?
  • Are providers delivering care that is later denied for coverage?


Common Revenue Gaps


When you look for gaps in prior authorization processes that may be leaking revenue, look at these functions:

  1. Patient pay: Are your prior authorization processes providing the information you need to engage patients in payment plans at the time of visit?
  2. Coding: Do you have professional coders on staff who know the nuances of treatments, surgeries, and imaging? Do your prior authorization systems automatically enter correct codes into the patient record?
  3. Billing: Is billing created under automated and accurate prior authorization? Is accuracy built into the billing system?
  4. Payors: Are you receiving the contracted amount every time?

Those are just a few of the places where revenue can be leaking from the practice. If it leaks, it can pour. Implementing prior authorization software ensures that accurate information leads to revenue.

Patient Pay, Patient Pay, Patient Pay

Yes, we are repeating ourselves, but this is either a source of stable revenue or that drip, drip, drip of leaking revenue. Ask yourself the following questions:

  • Do you know patient pay responsibilities when the patient is in the office?
  • Can you establish a patient pay plan and engage the patient at the time of treatment? Do you collect patient co-pays at the time of treatment?

If the answer is no to any of those questions, you are watching money walk out the door every time a patient leaves the office. The statistics in this regard are staggering:

  • Patient pay now accounts for up to 30% of accounts receivable for physician practices. 90% of patients are likely to pay before they see their physician
  • 70% are likely to pay at checkout
  • 40% are likely to pay after they leave the medical practice
  • 11% never pay

Solving the patient pay challenges in your practice will increase revenue and patient satisfaction. Knowing their financial responsibilities and engaging in the development of a patient pay plan reduces stress for patients. No one likes surprise bills in the mail.

These are just a few of the things you can do to improve the medical practice financial tactics you employ. Prior authorization isn’t going away, but you can wrangle it to the ground and exert control over it. Your physicians’ time, patient care, and revenue depend on it.

InfinxA Guide to Improving Your Prior Authorization Process

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