Solving the Top Challenges of Prior Authorizations in Healthcare

Navigating the healthcare system as a provider can often feel like an elaborate game of approvals, especially when it comes to the prior authorization process. Despite advances in technology, this critical element of maintaining financial health elicits groans from many healthcare professionals. Whether it's the complexity of payer policies or the labor-intensive bureaucratic process, prior authorizations pose significant hurdles, but solutions are available for providers who want to improve the process for everyone involved.

1. The Persistent Paper Chase

Despite the widespread digital transformation across the healthcare ecosystem, prior authorizations remain notably behind. The manual nature of the prior authorization process can be quite costly, yet the drive toward automation is stagnant, with one-third (33%) of authorization tasks remaining manual, using phone, fax or email to pre-certify procedures and only 31% using a fully electronic method. Plus, less than 60% of the market leverages an electronic prior authorization solution.

Prior authorizations still lag other types of transactions, including:

• Claims submissions (98% were fully electronic)
• Eligibility and benefit verifications (94% were fully electronic)

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Substantial reliance on paper-based documentation and outdated communication methods continue to prevail. Healthcare providers find themselves buried in paperwork for countless hours each week, leading to not just a significant loss of time and mounting frustration but delays in delivering patient care. Ninety-five percent of healthcare organizations say patients experienced delays or denials for medically necessary care due to prior authorization requirements.

Solution

Implement an electronic prior authorization solution that can streamline key parts of the process. A solution can automate the request process so staff time can be spent elsewhere handling higher-value tasks. Fortunately, healthcare finance leaders indicated in our 2024 RCM Transformative Trends Report that implementing an electronic PA solution is a top investment for the coming year.

Research shows that providers who use an electronic prior authorization solution would average a time savings of 11 minutes per transaction. Industry-wide, electronic prior authorization solutions could provide $317 million in savings of PA-related costs for providers.

2. The Endless Cycle of Back-and-Forth

Securing a prior authorization can often feel like an ongoing negotiation, characterized by endless back-and-forth communication between the healthcare provider and the insurer. This cumbersome and inefficient dialogue consumes valuable time and resources and heightens the risk of errors. For each form submitted, the possibility of a request for revision looms, further amplifying the administrative workload.

It's no surprise, then, that 88% of providers describe the burden associated with prior authorizations as high or extremely high.

Solution

Similar to eliminating the stereotypical paperwork with prior authorizations, solving the back-and-forth can also be achieved with an electronic prior authorization solution. Specifically, real-time status updates will cut down on the endless communication between providers and payers.

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3. Navigating the Insurer's Maze

Healthcare providers are tasked with complying with a unique set of prior authorization requirements for each insurer, navigating a constantly changing terrain of services and treatments.

Staying informed of insurers’ varying guidelines significantly represents a continual challenge, as these requirements can shift without notice depending on treatment specifics or at the insurer's discretion. The absence of universal standards leads to a fragmented and complex array of processes that providers must manage.

Additionally, these complex rules have led to a deteriorating relationship between providers and payers, as 78% of hospitals and health systems report their experience with commercial insurers is getting worse.

Solution

The solution is simple – an online hub – or rules library – that tracks all these requirements, keeping them up-to-date and easily accessible. Imagine the staff time saved when employees don’t have to play phone tag with payers, but rather focus on what really needs attention.

The prior authorization battleground is a multifaceted landscape of challenges, each presenting unique hurdles to providers. While these obstacles may seem daunting, they also represent opportunities for innovative solutions that can streamline processes, reduce administrative burdens and ultimately improve patient care.

Interested in how you can improve your own prior authorization process? Download our "Complete Guide to Prior Authorizations" for actionable insights on how to make the PA process less painful and transform what was once a bottleneck into a source of financial strength.