Tag: Ryan Chapin

Alleviating the Prior Authorization Headache  

Matt Bridge

By Matt Bridge and Ryan Chapin of AGS Health 

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. 

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