Prior Authorization process is comprised of 3 distinct steps:
- Eligibility: Is the insurance coverage active, what is the co-pay, co-insurance, etc.
- Referral Certification: Obtaining payer approval to refer a patient to a specialist
- Prior Authorization: Obtaining payer approval for medical procedures, tests, labs, equipment (DME), pharmaceuticals, hospital admissions and extensions, and expensive drugs covered under medical benefits
Outpatient procedures, inpatient admits, stay extensions, DME, tests, labs, drugs, etc. are approved or denied based on the payer policy guidelines (medical necessity and/or appropriate use criteria).
Problem: Each payer (thousands) has their own policy guidelines per procedure (thousands) which can change every 45-60 days. The lack of automation and real-time responses causes delays in approvals, higher rates of denials, requires administrative and clinical staff (FTE’s), and delays patient treatment and outcomes. Requests are based on proprietary and non-standard workflows, which differ payer to payer. Providers know from first-hand experience the pain and frustration of 30-60 minute wait times on hold when calling the payer’s call center for questions or follow up PA status.