By MARCIA LEIGHTON 

In a pre-COVID-19 world, prior authorizations were a top concern of CFOs as a major source of claims denials and rework. Prior authorization cost healthcare facilities billions each year because of claim corrections, write-offs for non-medically necessary procedures and denials for services insurance companies previously approved.   

With COVID-19 cases continuing to ebb and flow across the nation, hospital suspensions of elective surgeries are following suit. Many states that were spared during the initial surge of COVID-19 are now seeing a surge in coronavirus cases leading to elective procedure restrictions. Whereas other states are moving toward easing restrictions with the anticipated challenge of high demand and decreased provider capacity.  

As the COVID-19 situations continue to evolve rapidly and uniquely across the country, it behooves health leaders to update their prior authorization strategies now, regardless of the status elective procedures. With an estimated revenue loss of $58.5 billion per month for hospitals nationwide, hospitals will need to have the operational fortitude to ramp back up quickly when confronted with patients who delay care due to COVID-19 hospital exposure concerns. The challenge of ensuring prior authorization is obtained on time with no delay in care is critical – both for the hospital’s bottom line as well as the patient experience.   

The Double-Edged Sword 

Prior authorization is a double-edged sword. Prior authorization was created in an attempt to ensure continuity in care standards, improve safety and regulate costs. However, for healthcare providers, the prior authorization burden can be time-consuming and costly. According to an American Medical Association physician survey, an average of 64% of services requiring prior authorization take at least one business day and 30% take three business days or longer to complete. Additionally, the 2019 CAQH Index reports providers spend an average of almost $11 per transaction to conduct a prior authorization manually. 

Today, hospitals find their schedules begging for patients with no wait times, but are confronted with the inability to render care quickly enough as prior authorization is needed to ensure the service is covered. Add on the repercussions of significant staffing challenges due to furloughs and layoffs, and the already challenging prior authorization process intensifies.   

Prior Authorization Pitfalls 

The prior authorization process is very much understated and often doesn’t get the attention it rightfully deserves. Although the revenue burden of denied claims is a concern for hospital leadership, prior authorization teams don’t always receive the focused attention needed. Regardless if prior authorization is being obtained by the ordering physician’s office or the hospital, teams are often understaffed, undertrained and/or have workflows that are severely disjointed and very manual. While many insurance payers have established quick checking ability for determining if prior authorization is needed, access is often limited for those staff who need it the most.  

On average, the time spent to complete prior authorization accounts for approximately two business days of physician staff workload. The reality is that much of that time is spent on determining whether prior authorization is actually needed. Prior authorization is not required for all services. By identifying what services require authorization upfront, prior authorization teams get valuable time back to their workday. 

Prior authorization rules appear to be up for interpretation within the payer world, and as such patients are obliged to take a more active role. Imagine this scenario, a patient schedules an appointment for a diagnostic test. They ask the scheduler if they need to get prior approval from the insurance company or if the hospital or doctor’s office will take care of it. The patient is told that no prior approval is needed. The patient, not trusting this information, contacts their insurance company for verification. The insurance company confirms that prior authorization is needed. The patient has now become the go-between to resolve the misinformation, confusion and dysfunction that is indicative of prior authorization. 

A Path to Success 

Unlike its sister solutions, prior authorization is yet to be completely automated. So, how can we work to ease the burden and lessen the financial impact on hospitals?  

Perseverance is the hard work you do after you get tired of doing the hard work you already did. – Newt Gingrich, American politician, historian and author 

Leading a successful prior authorization team or department takes perseverance, dedication and strategy. The most effective teams have the knowledge to anticipate issues with scheduled services, and work with the referring physician and team to provide the necessary documentation to ensure a smooth claim process. Prior authorization success comes from comprehensive payer knowledge. 

Know the Payer 

An effective prior authorization team can detect patterns or commonalities between requests. For instance, Blue Cross might not require prior authorization for a procedure when the diagnosis is X, or Aetna will deny a prior authorization request for Y when the patient has not completed physical therapy first. 

It is imperative these patterns or commonalities are well documented and easily referenced by staff. Documentation is extremely valuable and plays a significant role in increasing productivity especially when staff turnover, sick day or vacation time is experienced. Comprehensive payer documentation must include an easily accessible common rules repository to identify: 

• When prior authorization is required by the payer 
• Which payers have a procedure code tool that identifies when prior authorization is required  
• Each payer’s prior authorization process timeline 

With payer knowledge at your staff’s fingertips, teams and workflows can be structured to accelerate the prior authorization process by identifying potential delays and resolving issues at pre-access.  

Incorporating a reliable method of following up on prior authorization requests, via EHR work queues or shared documents, is vital. To illustrate the value, revisit the previous scenario where the patient was acting as go-between. The patient has learned prior authorization is needed but later learns from the imaging center that the physician order was not completed correctly for it to be covered by the insurance company. The facility’s team understood the payer’s processes and prevented a denial upfront by anticipating the result. 

There are many improvement opportunities when it comes to prior authorization, but comprehensive payer knowledge is key. Streamlined workflows that reflect payer rules, timelines and policies can ensure prior authorization is obtained on time and without a delay in care.  

Effective prior authorization management is essential to efficient, cost-effective and timely healthcare under any circumstance. The COVID-19 pandemic has only reinforced the need for healthcare leaders to champion prior authorization transformation by being engaged, thoughtful, following through. Reducing the prior authorization burden benefits everyone – insurance payers, healthcare providers and patients alike. 

Marcia Leighton is the executive director of client services at PatientMatters, a patient access and advocacy solutions leader. With over 15 years of experience, Marcia’s expertise includes patient life cycle workflow and data systems improvement in both the clinical and financial healthcare sectors. You can reach her at Marcia.leighton@patientmatters. Visit www.patientmatters.com.