In just a few months, your pre-authorization world will be turned on its head. Forces including changing regulations under the ACA, and more complex coding issues under ICD-10 mean that by the end of this year, the way you approach pre-authorization in radiology probably will not work anymore.
The answer to this problem is taking a deliberate and strategic approach, so that you can skip all the challenges ahead and see benefits including:
• Authorization appointments processed well within time
• Obtaining a high percentage of authorizations
• Low pre-authorization denial rates because of complete, accurate, and properly-tracked documentation
If you want to pro-actively address the issues around pre-authorization that you’re undoubtedly going to run into this year, this article will serve as a guide in identifying challenges in the pre-authorization process, rethinking your workflows, and zeroing in on a solution that will carry you forward efficiently and effectively into the future of healthcare.
Your Challenges In Pre-Authorization:
Understanding your challenges around pre-authorization is incredibly important. If you aren’t able to list and describe them, you won’t be able to address them properly.
Based on our deep experience with clients in the area of pre-authorization, here are some of the most pressing problems you’re likely facing:
• A lack of workflow management
• Operations managers who are unable to track the progress of an end-to-end pre-authorization process
• High levels of preventable denials
• Providers submitting incomplete, or incorrect information
• Systems that are not optimized to achieve lower TAT and high approval rates
• Lost or decreased revenue
• Using a vendor who charges high fees for mediocre results
Many of these issues stem from radiology providers typically taking a passive-aggressive role in the pre-authorization process. Previously, this was recommended, since imaging facilities shouldn’t step into the area of providing services where preauthorization is required, but hasn’t been obtained.
Unfortunately, that leaves providers like you at the mercy of the practices of referring physicians — physicians who often aren’t reliable and who, as the healthcare environment changes, will be even more prone to dropping the ball as the pre-authorization process itself becomes more complicated.
This is why, going forward, radiology practices and groups will need to be more proactive, and will need to change their perspective on multiple fronts. Two of the most important ways you can do this, are rethinking your perspective on accounts, and taking an active and strategic approach to workflows.
The Age Of The Individual Account:
The entire healthcare industry is moving toward patient-centered care, and radiology revenue cycle will have to follow suit.
This means that each account will need to be addressed with an active acknowledgement of all the forces acting on it. Those forces include the ACA, ICD-10, and individual payor behavior.
A) The Affordable Care Act: You’re undoubtedly already feeling the impact of the ACA on your pre-authorization processes. While not all plans are directly affected, some are, as in the case of self-insured plans, which, according to the act, now have requirements around pre-authorization and emergency services. As things continue to shake out, and states find their footing, expect to see an increasingly diverse mix of both patients and plans, both of whom will present new challenges to your gatekeepers and staff.
B) ICD-10: Not all carriers will be required to switch to ICD-10 (workers’ compensation and auto plans to be specific), so you will still be working with ICD-9 coding, procedures, and forms on these accounts. Your staff will have to be trained to keep their eyes open for accounts that aren’t yet going through the transition, and that’s in addition to all the changes in coding and forms that will come with accounts to which the ICD-10 implementation does apply. And remember, you’ll need to have your training and testing complete one month before October 1. If there’s one piece of action that most experts recommend around ICD-10 preparation, it’s to start now.
C) Payor Reactions: The shifting world of healthcare reimbursement has meant payors tightening up their procedures, and getting much stricter about what they will and won’t allow. Each payor is finding their own ways of not reimbursing accounts, so your staff, software, and processes will have to be sensitive to account nuances to make sure you’re adhering to individual payor and plan standards.
The Impact Of Workflow:
If you haven’t established best practices in your workflows, now is the time. A little investment now will save you an incredible amount of headache in the future.
To get you started, we’d like to share with you the workflow model we recommend with our Medical Pre-authorization Solution. It is a stage-oriented, comprehensive model that helps to ensure almost 100% approval rates, pushes you over a 99.5% accuracy rate, and drops your turnaround times to as low as 10 minutes.
- Case Preparation: Cases are prepared by researching relevant codes, patient history, symptoms, and pre-requisites.
- Addressing Payor Questions: Payor questions are answered to justify exam requirements.
- Addressing Complex Cases: Difficult cases that require multi-layer questions are handled by obtaining additional information and documents that are either with you or the physicians.
- Pre-authorization: Prior authorization and important case details are obtained.
A systematic approach like this one is not only key to understanding your pre-authorization process, but also in determining training needs, identifying areas of leakage, and creating preparation plans to react to state and federal regulatory changes in productive ways.
Starting On A Solution Today:
We know that you’re busy providing excellent service to your patients, and that that’s what you do best. What we do best is process management for radiology providers, and pre-authorization is one of our strongest competencies.
We’ve brought all those competencies together in our powerful and affordable iBridge solution — a solution designed to bring you 52% per-transaction cost savings over other, comparable solutions with similar features. For that cost, you receive benefits including fast STATs (within 30 minutes, same day appointments within 4 hours), 100% accuracy, and 100% adherence to a 24 hour TAT.
iBridge is effortless to use, and features benefits including:
A. Comprehensive workflow management
B. Tactical and business dashboards
C. Cross-team communication that facilitates information and documents
We don’t want you to just take our word for it though. Take a few minutes to read about one of our real-life client experiences, and get a preview of how iBridge and Infinix can simplify your pre-authorization life.