A Buyer’s Guide to Prior Authorization
Prior authorization is a management process by which health care providers obtain approval from payers before delivering specific services in order to prevent lost revenue and reduce expenses.
The case for digital prior authorization
The current prior authorization process is extremely burdensome and time-consuming–the average physician must complete 41 prior authorizations per week, which translates into about 14 labor hours just for completing prior authorizations, according to a 2020 American Medical Association survey. It's also one of the most costly administrative transactions, with an average expenditure of about $11 for each request. But the prior authorization landscape is changing, and the lost time and sunk costs are decreasing as intelligent automation becomes commonplace.
While a manual prior authorization takes an average of 21 minutes, a digital transaction can be completed in about four minutes, with fewer denials and faster turnaround time.
“We've seen a steady shift in the industry–the results are undeniable. Health systems are turning increasingly to digital prior authorization solutions that leverage robotic process automation (RPA) to generate, submit, and monitor the status of prior authorization requests. Organizations doing this well are seeing millions of dollars in additional revenue.”
— Patrick Higley,
Senior Director at AVIA
What is prior authorization?
Prior authorization–sometimes called precertification or prior approval–is a management process by which health care providers obtain approval from payers before delivering specific services in order to prevent lost revenue and reduce expenses. When patients seek prior authorization–typically for more complex or costly treatments or prescriptions–payers may approve or deny requests, ask for more information, or require that the patient receive an alternative treatment before approving the initial request.
How digital prior authorization process works
While the steps remain unchanged between digital and manual processes, an end-to-end automated solution alleviates the administrative burden and virtually eliminates errors that can lead to delays and denials.
Determine prior authorization requirements. The leading solutions continually scrape payer sites to maintain real-time information on tens of thousands of payer policies.
Complete the prior authorization form. Intelligent prior authorization software identifies and fills out the appropriate prior authorization form based on the patient’s specific payer requirements.
Collect the appropriate documentation. The leading solutions automatically collect and append clinical documentation from the EHR. Staff can review and validate information prior to submission.
Submit the request for prior authorization and monitor for status updates. After staff review and approve the request, it’s automatically submitted through the appropriate web portal. An intelligent dashboard displays real-time status updates.
What leading digital prior authorization solutions offer
Requirements identification
Top solutions automate whether a prior authorization is required and can identify payer-specific rules without additional manual research from staff.
Requirements knowledge base
The prior authorization requirements knowledge base should be continually and automatically maintained, with minimal (if any) support from the health system.
Automated form completion
Leading prior authorization solutions integrate with the EHR and leverage structured and unstructured data to populate the appropriate fields and save time for physicians and staff.
Forms library
End-to-end solutions should include a forms library, where necessary payer-specific forms can be created and maintained.
Documentation collection
Intelligent documentation collection automatically pulls necessary documentation from the EHR and helps reduce denials based on incomplete or missing information.
Automated request submission
Capabilities should include automated submission on behalf of the provider through efax, payer portals, third-party sites and other access points.
Status monitoring
The leading solutions offer continuous status monitoring and push update and other relevant information back to the appropriate work queues and fields in the EHR.
Organizing for digital prior authorization success in your health system
Before implementing end-to-end automation in the prior authorization process, hospitals and health systems must:
Have a mature EHR with no planned changes in the near future.
Ensure that prior authorization practices are documented and standardized.
Obtain organizational buy-in from revenue cycle leadership and operations.
Other capabilities that health systems should deploy to successfully implement digital prior authorization include:
Mechanisms to track prior authorization performance at the department and leadership levels.
Integration with business systems like EHRs, call center tools and customer relationship management–this eliminates duplication of information and ensures accurate data capture.
Strong internal communication to educate staff about prior authorization capabilities and appropriately calibrate responsibilities.
Open lines of communication across payer relationship and revenue cycle teams to efficiently respond to procedural changes and resolve problems.
Interested in learning more?
Save the topic on AVIA Marketplace to get notified about new prior authorization insights and get personalized vendor recommendations.
AVIA Marketplace is where innovative health systems and hospitals go to find the right digital health solutions. It’s built to efficiently search vendors and guide informed decisions, with tools like product comparisons, match scores, report generators, peer reviews, and market insights.
Brought to you by AVIA, a trusted company and community of experts who guide health systems on their digital transformation journey.