Looking back at this year’s healthcare innovation, we have seen a lot of changes in prior authorization. The prior authorization process is changing from the inside out with progress in machine learning and the implementation of artificial intelligence.
Topping the transformations this year, sophisticated health plans have started adopting green lighting. While gold carding is quite common in the health plan and prior authorization process, greenlighting exceeds the regulatory minimum in delivering superior results.
Legislation like gold carding and CMS’ PA and interoperability rule have created external pressure on the change of authorization processes.
Let us dig deep into the three disruptors creating turmoil in the preauthorization status quo.
1) New regulatory requirements both state and federal are pushing forward-thinking plans for smart health plans to ensure efficient prior authorization solutions.
Both government and private insurers are focusing on implementing industry-comprehensive technologies that can enhance the prior authorization processes. For instance, the Medicare Advantage plan has a special focus on implementing clinical intelligence to guide high-value choices for care which will eventually improve patient health outcomes.
2) The administrative load of prior authorization is expected to be lessened by the conversion of intake channels from fax and other manual, fragmented sources.
A survey by the American Medical Association suggested that 90% of physicians agreed that prior authorization services hurt the care process. A massive percentage of preauthorization requests are still submitted via fax. This results in healthcare administration lagging and there is a fall in the productivity curve.
At the same time, the industry is not utilizing the modernization of the processes. However, the changing market and patient behavior are pushing the implementation of machine learning to digitize authorization requests.
This will help providers and healthcare facilities incorporate longitudinal patient information and real-time feedback on requests, which will reduce the time required to obtain authorization requests.
3) Green lighting, a more targeted approach than gold carding will speed up or demolish the prior authorization process.
Physicians and healthcare facilities who have a prior authorization approval rate over 90% during six months are free from prior authorization requirements under a new Texas law, called “gold carding”.
4) Robotic Process Automation is about the hit the market eliminating the challenges of the prior authorization process.
The traditional authorization process involves tedious and complicated paperwork, and the submission process is also slow.
However, upcoming robotic process automation (RPA) in the prior authorization process is more efficient in identifying missing patient information, predicting approval likelihood, and triaging cases for human review to increase speed in identifying and denying claims, potentially impacting patient care.
To Summarize,
Technology and changes in administrative protocols are transforming the healthcare industry and providers are tangled with excessive administrative tasks and patient care.
Providers need to adapt according to the changes in payors’ claim submission guidelines and coding regulations. As the debate regarding the effectiveness of authorization is going on, outsourcing of prior authorization services has emerged as a feasible solution for most providers across the country.
Partnering with a prior authorization company can eliminate the challenges in the PA process and help you in enhancing overall administrative processes so that your practice is financially and functionally stable.
