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.
By Matt Bridge, senior vice president – Strategy and Solutions, AGS Health.
Optimizing financial clearance and other patient access operations is an important aspect of any strategy to offset revenue cycle issues that are behind more than half of all claim denials. Healthcare organizations struggle to do so, however, thanks to staffing and technology limitations that impede efficient operational processes and increase front-end authorization errors.
Those barriers are starting to crumble as artificial intelligence (AI) and automation become more deeply embedded in healthcare revenue cycle management (RCM). Of particular note is the emerging subset of tools designed to streamline and expedite aspects of financial clearance operations, including eligibility and benefits determination and prior authorization processes. Early adopters of these intelligent authorization tools are reporting rapid return on investment (ROI), including 70% to 85% faster eligibility and benefit determination and 85%-90% improvement in authorization determination time.
Also being reported are 65% to 80% less time on authorization initiation and authorization follow-up times that are up to 85% shorter, as well as 80% faster price estimating. The result of these improvements is not only higher revenue growth and employee retention, but an improved overall patient financial experience.
Challenges to Financial Clearance
Operational inefficiencies, outdated technology, and staffing limitations are among the main contributors to rising denial rates, which were up to nearly 12% in the first half of 2022. More than 41% of those denials are the result of front-end RCM issues, including eligibility, authorization, and other financial clearance activities, which also contribute to higher net revenue leakage via avoidable write-offs.
Breakdowns in the financial clearance process can also drive down patient experience scores, with one survey reporting that 93% of patient respondents indicated provider loyalties hinge on their financial experience and more than half said it also impacts their decision to refer a friend or family member. Forty-one percent said they’re unhappy with their overall medical billing experience, with many pointing to a lack of pricing transparency or certainty despite the No Surprises Act mandate to provide them with both.
One cause is the critical shortage of RCM professionals. More than 60% of providers face RCM staff shortages, and nearly half of CFOs and revenue cycle vice presidents from large health systems and physician groups say their labor shortages are severe, with four in 10 reporting vacancy rates between 51%-75%.
The opportunity to resolve these challenges while also eliminating error-prone manual processes from financial clearance is why nearly 80% of healthcare organizations surveyed are turning to AI and automation. Financial clearance and its redundant and time-consuming tasks is a prime candidate for AI and automation, with 42% of respondents to one survey saying their organization would benefit most if eligibility checks and prior authorizations were automated.
