The prior authorization process has evolved in complexity as the healthcare industry transitions from fee-for-service to value-based care. At the same time, payers are expanding the number of services subject to prior authorization to establish medical necessity and appropriateness. It’s a one-two punch that leaves providers and provider organizations struggling under the weight of a prior authorization burden that, left unaddressed, can have long-term revenue cycle impacts.
Today’s prior authorization process involves time-consuming steps, including gathering and submitting medical documents to insurance companies and waiting for approval. It also often involves dealing with denials and appeals – all while guidance around required documentation becomes stricter.
The number of procedures subject to authorization is also expanding, creating new challenges for staff who must understand the clinical documentation and office notes necessary to support the authorization. This also means the addition of new administrative requirements with far-reaching impacts on finances, operations, and patients. Additionally, when establishing a centralized prior authorization team is infeasible, expanded prior authorization needs exacerbate the problem of competing priorities for staff tasked with obtaining authorizations amidst other core responsibilities, including patient care.
Prior Authorization Challenges
The impact of today’s challenging prior authorization environment is felt in three key areas: financial, operational, and the patient experience.
On the financial front, the administrative burden of prior authorization has increased steadily over the years, leading to additional costs and workload. Among the most significant financial impacts are higher administrative costs and reduced or lost revenues due to denials, which can be difficult to overturn. The prior authorization process can also delay cash flow.
Life after a traumatic brain injury can be challenging. It can result in severe cognitive and physical limitations. While it’s possible to recover, you may experience sensory issues, cognitive impairment, and other challenges. Traumatic brain injury (TBI) victims may require additional assistance to perform their daily life activities. This is where assistive devices and technologies come in. They enhance a TBI survivor’s quality of life while boosting their independence. Discussed below are several assisted devices and technologies for traumatic brain injury victims.
Mobility aids
Traumatic brain injuries happen due to various incidents or accidents, such as falls, auto crashes, or sports-related injuries. These injuries can cause severe, lasting disabilities like physical limitations that need the use of mobility devices. These aids include:
Walking stick: It’s a one-legged cane or stick with a gripped handle for supporting and holding an individual. They’re perfect for TBI victims who can walk with little help
Rollator frames: They’re four-wheeled frames that users push along as they walk. They’re suitable for balance defects or limited mobility but can still walk unaided
Wheelchairs: They’re best for those who cannot move unaided
Quad stick: It’s suitable for those who can move freely without help
Electric wheelchair: It’s electric motor powered and perfect for those who want to travel long distances but can’t move without help
With the help of physical therapists and specialists from trusted TBI care facilities, you can select a mobility aid suitable for your loved one’s needs.
By Michael Bradford, head of operations of Americas, HappyOrNot.
In today’s healthcare, organizations encounter several obstacles while trying to provide high-quality treatment to patients, such as limited resources and the ever-changing demands and expectations of patients, to name just a few examples.
This means that healthcare organizations are under increasing pressure to deliver outstanding patient care to be the provider of choice. Dissatisfaction among patients and the economic climate, which has personnel issues impacting the industry’s capacity to adequately address patient needs, have intensified the sense of urgency.
Common Patient Complaints and the Need for Improved Care
When patients voice their dissatisfaction, it usually leads healthcare providers to new opportunities for improvement. Long wait periods, impersonal treatment, and inadequate communication are among the most common grievances.
Patient satisfaction is greatly affected by communication issues, especially when healthcare practitioners are viewed as being uncaring, according to research conducted by the National Institutes of Health (NIH). Patient satisfaction and health outcomes are negatively impacted by long wait times, according to the American Journal of Managed Care, and healthcare organizations must address these concerns by using new solutions that improve the patient experience.
Economic and Staffing Challenges in Healthcare
Due to tight budgets and staffing challenges, hospitals’ provision of good patient care is hampered. According to the American Hospital Association, health service systems have been stressed by a shortage of manpower, especially since the international health crisis.
Staff cutbacks will impose even more strain on already overworked people, reducing their capacity to give each patient the individual attention they deserve. Given these constraints, it is of the utmost importance to examine possible substitutes for the sake of upholding and improving the quality of patient care.
The Imperative for Solutions in Patient Experience
For hospitals looking to better understand patient experiences and how they might be improved, data analytics and artificial intelligence offer significant opportunity. As AI’s analysis of vast quantities of patient data shows, information on treatment outcomes, organizational efficiencies and patient satisfaction can be uprooted and used to make strategic decisions.
When doctors and hospitals work from this novel information, they are able to come up with approaches better suited to each patient’s individual needs and tastes. Take, for example, patient flow. By integrating predictive analytics into it, wait times for patients can be decreased.
Generative AI, until recently an uncharted frontier, is now encountering regulatory roadblocks. Fueled by minimal oversight, its meteoric rise is slowing as frameworks take shape. Businesses and users alike brace for the ripple effect, wondering how increased scrutiny will reshape this booming sector.
While AI automation could revolutionize efficiency and speed up processes in many customer-facing industries, healthcare demands a different approach. Here, “consumers” are patients, and their data is deeply personal: their health information. In this highly sensitive and regulated field, caution takes center stage.
The healthcare industry’s embrace of AI is inevitable, but the optimal areas for its impact are still being mapped out. As new regulations aim to curb this disruptive technology, a crucial balance must be struck: fostering smarter, more efficient AI tools while ensuring compliance and trust.
The Need for Regulation
Regulatory mechanisms and compliance procedures will play a crucial role in minimizing risk and optimizing AI applicability in the coming decade.
These regulations must be developed to effectively safeguard sensitive patient data and prevent unauthorized access, breaches, and misuse—necessary steps in gaining patient trust in these tools. Imagine the added friction of AI systems that misdiagnose patients, spew incorrect information, or suffer from regular data leaks. The legal and financial implications would be dire.
Optimized workflows simply cannot come at the cost of unaddressed risks. Regulated and responsible AI is the only way forward. And in order to achieve both, three foundational pillars must be met: explainability, control, and compliance.
Imagine this: physicians spend more time with their patients than with their paperwork. Billing is quick and accurate, with minimal denials. Healthcare workers enjoy a positive work/life balance. Thanks to the rapid advancement of AI, this vision of healthcare is becoming increasingly possible.
Health system leaders are already investing toward this ideal state. From roundtable discussions at Healthcare Financial Management Association and Becker’s Healthcare to Zoom chats every week, I’ve connected with many C-suite executives at health systems about their expectations for AI. There is, across the board, a clear set of priorities for the next one to two years. The overarching vision is not just to integrate new technologies but to do so in a way that delivers tangible improvements in workforce experiences and satisfaction, revenues and costs, and patient care outcomes.
Here are a few resounding themes that I’ve heard.
Proving ROI
Proving ROI on AI investments is crucial: put plainly, you want to ensure you’re getting more than enough bang for your buck. Applications of AI need to map back clearly to measurable cost and revenue impacts. Health system CFOs expect predictable ROI and are screening new technologies closely.
Many AI tools on the administrative side can meet this proof of hard ROI. For example, organizations like ApolloMD have experienced significant improvements in coding efficiency and revenue capture by minimizing coding errors and denials through autonomous coding.
While vendors typically report impressive ROI from their technology, any vendor worth its salt will agree to a proof of concept allowing you to test and validate impact for your organization. For example, an easy way to build confidence in autonomous coding is to compare coding results between your team and the AI system before committing to go-live.
Increasing end-to-end strategies
Many AI tools have surfaced to address a single use case. However, health system leaders are more interested in comprehensive, integrated solutions across departments. Consider the case of ambient documentation and autonomous coding: ambient documentation works as a medical scribe using AI to document clinician-patient encounters, and then autonomous coding steps in as a medical coder to translate and assign the necessary codes for billing.
These types of end-to-end strategies are more compelling and impactful. Health system CEOs increasingly gravitate toward them to ease administrative burdens, speed up visit-related processes, and enhance patient outcomes. The market is supporting this expectation: Abridge, an ambient documentation platform, recently raised $150 million in funding, and Google Cloud added an autonomous medical coding solution to its marketplace earlier this year. Used in conjunction, these technologies offer more integrated – and more valuable – strategies for health systems.
By Sussan Nwogwugwu, DNP, PMHNP, Clinical Leader, Done.
Physician burnout, characterized by exhaustion, compassion fatigue and feelings of inadequacy, not only affects physicians; it also affects their care quality, which ultimately compromises patient well-being.
Collaborative care benefits physicians – and patients – alike.
Primary physician burnoutby the numbers
The American Medical Association said that burnout symptoms affected almost 63% of physicians in 2021, a significant increase from the previous year.
Primary causes of burnout include “the practice of clinical medicine… your specific job… having a life… the conditioning of our medical education… and leadership skills of…immediate supervisors,” according to the AAFP. A collaborative care model can remedy burnout.
The benefits of collaborative care
Psychiatry.org says a collaborative care team “is led by a primary care provider and includes behavioral health care managers, psychiatrists and… other mental health professionals… The team implements a measurement-guided care plan based on evidence-based practice guidelines and focuses particular attention on patients not meeting their clinical goals.”
In addition to decreasing clinical workloads, this collaboration also leads to improved feelings of job satisfaction. Further, clinicians experience lower levels of isolation, and a collaborative environment enables knowledge-sharing, ultimately enabling professional growth.
In addition to benefiting clinicians, collaborative care benefits mental health patients by improving access to holistic, specialized care. For patients with chronic conditions, it is especially advantageous.
Components of comprehensive care
Comprehensive care, according to AAFP, is “prevention and management of multiple physical and emotional health problems of a patient over a period of time...”
Its three pillars include impact analysis; evidence-based interventions; and an inclusive patient approach incorporating frequent reviews. Comprehensive care that’s baked into a collaborative care model helps enhance clinician well-being and reduce the burden on primary care providers. It also benefits patients who receive care under this model.
We’ve come a long way since the University of Nebraska pioneered two-way video communication for telemedicine in 1959. Today, telehealth enables healthcare providers to expand access to medical support, improve patient convenience, streamline workflows, and enhance clinical outcomes. But as telehealth has grown, so too have the regulations around it.
The software behind telehealth — including on laptops, tablets, the cloud, and increasingly AI — requires careful governance and robust security protocols to ensure patient privacy in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
The following explores how telehealth can alleviate administrative burdens and create a more efficient experience, while HIPAA compliance ensures the product is safe for both patients and providers to trust.
HIPAA Compliance Builds Patient and Clinicians’ Trust
While demand for digital health adoption from patients (33%) and providers (36%) is rising, over half of clinicians surveyed are still concerned about data breaches or malware attacks on their healthcare data, global advisor HIMSS (Healthcare Information and Management Systems Society) reports.
Securely communicating sensitive patient information (PHI) within a healthcare organization can be challenging when relying on everyday tools like SMS, Skype, and email. While these platforms offer encryption mechanisms, they fall short in two key areas.
Firstly, achieving effective encryption requires a uniform environment. Everyone within the organization must use compatible operating systems and the same encryption/decryption software. This uniformity can be difficult and expensive to maintain across a large organization with diverse devices and software versions.
Secondly, even with encryption, the service providers themselves — like Verizon, Skype, and Google — still have access to the underlying data on their servers. Business associate agreements (BAAs) can be established to address these concerns, but these rely on the providers to maintain the integrity of the encrypted data. Here, Skype’s past actions raise red flags, and it’s fair to question if major communication companies like Verizon or Google would be comfortable with the additional responsibility and potential legal implications of healthcare data breaches.
Intuity Medical, Inc., a medical technology company committed to making it easier to live with diabetes, announced today that its POGO Automatic® Blood Glucose Monitoring (ABGM) system, featuring one-step testing, is now covered by Medicare Part B. This decision expands access to the innovative monitor for the 16.5 million seniors age 65 and up living with diabetes.
The Centers for Medicare and Medicaid Services (CMS) created two new coverage codes specifically for POGO Automatic, recognizing this new and significantly different technology compared to traditional blood glucose meters (BGMs). POGO Automatic features an all-in-one design that integrates testing supplies into a 10-test cartridge.
As the first and only FDA-cleared automatic blood glucose monitoring (ABGM) system on the market, POGO Automatic revolutionizes diabetes management by allowing people with diabetes (PWD) to easily test their glucose levels without disrupting their daily activities. Its one-step process automates the multiple-step glucose monitoring process associated with traditional BGMs, making it easier for many seniors to check their blood glucose.
Recognized by healthcare professionals for its user-friendly design which can improve testing compliance, POGO Automatic is endorsed as the ideal solution for many diabetes patients by Rosemarie Lajara, MD, an endocrinologist with Southern Endocrinology & Diabetes Associates, P.A. in Plano, Texas:
Life after a traumatic brain injury can be challenging. It can result in severe cognitive and physical limitations. While it’s possible to recover, you may experience sensory issues, cognitive impairment, and other challenges. Traumatic brain injury (TBI) victims may require additional assistance to perform their daily life activities. This is where assistive devices and technologies come in. They enhance a TBI survivor’s quality of life while boosting their independence. Discussed below are several assisted devices and 
By Michael Bradford, head of operations of Americas, 
By 
Intuity Medical, Inc., a medical technology company committed to making it easier to live with diabetes, announced today that its POGO Automatic® Blood Glucose Monitoring (ABGM) system, featuring one-step testing, is now covered by Medicare Part B. This decision expands access to the innovative monitor for the 16.5 million seniors age 65 and up living with diabetes.