Automated Real-Time Prior Authorization:
Benefits, Barriers, Informatics In Context’s Value Proposition
BENEFITS OF PRIOR AUTHORIZATION
- Prior authorization is the closest assurance providers receive from payers guaranteeing payment for treatment.
- When the process is automated and real-time, prior authorization can reduce post-service denials, re-submissions, medical reviews, physician and clinical staff time, and patient rescheduling, and in turn improve patient satisfaction scores.
BARRIERS TO EXPANDING PRIOR AUTHORIZATION
- Lack of automation and real-time responses causes delays in approvals, higher rate of denials, requires administrative and clinical FTEs, and delays patient treatment and outcomes.
- Requests are based on proprietary and non-standard workflows, which differ payer to payer.
- Resistance to expanding prior authorization because of its manual and proprietary nature.
- Frustration and Pain: 30-50 minutes wait time on hold when calling the payer’s call center.
INFORMATICS IN CONTEXT’S VALUE PROPOSITION FOR PROVIDERS
- Significantly simplifies administrative processing, reduces unnecessary delays, lowering costs by an order of magnitude.
- Software-agnostic solution based on EDI 278, the electronic standard for prior authorization.
- Uniformity and standardization of workflow within a multi-payer offering.
- Provider portal (or integrated web service) is easy to use, promoting high utilization while reducing unnecessary delays and call volumes by integrating the patient eligibility function with an electronic prior authorization request.
- Prior to submission, requests are reconciled against payer policies, ensuring compliance, reducing possibility of denials, appeals, medical reviews, and increasing patient outcomes.
- Advanced analytic triggers can be applied to payer payment patterns, physician referral patterns, real-time calculation of incurred costs, and more.
- Redirect limited resources to other care management functions without increasing budget.
- Patient procedure approval and payment transparency at the point of care. If the provider receives automatic treatment approval, patient can be scheduled and informed the co-payment amount.