Payers have continued expanding the list of services requiring prior authorization. The implementation of this utilization management is to ensure that the care provided is medically necessary, delivers high quality, and is cost-effective. Though the PA process was initiated as a cost-control measure, it has now become a ‘necessary evil’ for the providers and patients. It involves time-consuming steps that include gathering and submitting accurate and detailed documents to payers to obtain timely and correct reimbursements. On top of that, every year the guidance is becoming stricter around the extensive documentation required for preauthorization. Procedures have been added that did not historically need authorization. It is a growing challenge for the providers to understand and implement the current industry standards in the PA process considering the evolving guidelines.
In this article, we have discussed some of the major challenges that are hampering the authorization process, and possible strategies to overcome them.
5 Prior Authorization Challenges
1) Rise in requirements and staff shortages
Consistent staff shortage is a common problem in the healthcare arena, and over the years the problem has taken a steep growth. Additionally, studies have suggested that prior authorization requirements are increasing every year, which makes it difficult for providers to obtain approvals for treatment.
Another survey has shown that more than 50% of the health systems have more than 100 open roles to fill operational positions. And with all these vacant roles, the existing staff are under the pressure of accomplishing more administrative tasks.
2) Ever-changing payer rules
The diverse payer rules and transformations within the same in a frequent manner are hindering the prior authorization process. Along with that, every patient’s health plan has different requirements. Three major aspects are making it more difficult for the providers-
- Inconsistencies in requirements across the payers
- Vague or opaque PA requirements
- Frequent changes in documentation requirements
These factors together leave more room for errors within the process and lengthen the time an authorization takes.
3) Time-consuming process
The PA process is a time-consuming, labor-intensive, and often frustrating process. There are numerous steps involved within the process along with a minute documentation requirement. While simply submitting an authorization takes 12 minutes, the lack of understanding of the process leaves room for non-compliance and prior auth denials. The continuous back and forth of the request between the provider and payer makes it more time-consuming and tedious.
4) Administrative burden and burnout
With the prevalence of chronic conditions, the patient volume in different specialties is increasing and so are the PA requirements. Furthermore, the shift of care model from fee-for-service to value-based elevated the documentation requirements within the process. This single-handedly increased the administrative burden on the existing workforce and led them towards burnout at a faster pace.
5) Benefits and coverage gaps
It is not always necessary that there is erroneous coding or late submission. It might happen that the requested services are not covered under the patient’s insurance coverage benefits or the patient is not eligible for the services. Hence, there will be a chance of prior auth denial.
Multifaceted Impact of Prior Authorization
1) Financial Impact
The administrative burden over prior authorization services has increased over the years leading to additional expenditures and workload. For instance, denied authorization often leads to revenue loss whether upfront or during processing. Also, the patient might skip the care process entirely once they come to know that the insurance company is not going to cover the procedure or service.
2)Operational Impact
The time spent on obtaining authorization takes away time from the core activities of patient care. Often, your existing staff is burned out by trying to maintain a balance between patient care and administrative responsibilities. Also, the complexities within the process lead to errors and delays or denials in care, resulting in a negative impact on patient satisfaction and quality of care.
3) Patient Issues
Delayed care is the most prevalent issue when it comes to poor prior authorization processes in your facility. Reduced accessibility to care potentially leads to poor health outcomes. Furthermore, patients may be responsible for the cost of care if the authorization is denied. This ultimately leads to confusion and frustration among the patients leading to poor patient satisfaction and negative experience.
Achieve Prior Authorization Success with Experts in California
Opting for people strategies to resolve issues in prior authorization in California is a feasible option for numerous providers. Hiring experts from a reputable revenue cycle management organization can resolve all your issues with authorization. You must ensure that you have the right resources in place to manage the prior auth conundrum. Outsourcing virtual assistants can help you standardize the process as per the industry requirements. The experts in these companies are well-versed in industry-comprehensive technologies and prior auth regulations, which helps you stay abreast of the competitive edge.
When it comes to efficient management of your RCM services, opt for a reliable organization that can streamline your practice’s operations and optimize revenue in the long run.
