In the current U.S. climate, healthcare can be quite intricate and confusing to many who are unacquainted. With insurance, you would think things would be easier, but rather it introduces new rules and restrictions to the mix. Most often, if a patient has insurance, the healthcare provider will have to request prior authorization (PA) from the insurance payer prior to rendering the care. This is to make sure that the insurance payer will pay for the service once it is billed to them.
But this idea was thought up by insurance companies to make sure that their resources were conserved and there wouldn’t be any overuse of insurance plans for frivolous spending. Unfortunately, waiting for each insurance payer to respond for each of their clients at your provider’s office creates a tight bottleneck, and more often than not leads to significant delays in patient care. It’s no easier on the healthcare provider’s employees either.
There are 6 main steps that are involved with prior authorization. Firstly, someone must manually check patient details and determine if prior authorization is required for the planned procedure. Once it’s deemed necessary, the patient’s medical charts and clinical documents must be read to determine if the patient fits the prior authorization guidelines. Once all that is complete, the PA request is sent to the insurance company via fax or online portal. This step alone costs the patient 15-20 minutes per patient.
After the request is sent, an employee must constantly call, email, or check the portal to check the status of the prior authorization request. Then, if the request is denied, the staff must compile all the documents again and resubmit them along with an appeal letter. Lastly, once the request is finally accepted, staff must manually update the clinical documents to reflect this prior authorization approval.
While this seems straightforward, it is costly in both time and money. With an average of $11 and 20 minutes per patient, this leaves a high burden on provider’s offices with a large number of patients. Furthermore, the number of denials is on the rise as well. 3 in 4 doctors have seen some increase in the past 5 years and 27% of physicians say their prior authorizations are almost always denied. But nearly half of providers’ offices don’t have the time, staff, or resources for the appeal process.
Another confounding factor is the time sensitive nature of patients’ health. Nearly half of physicians say their patients’ health can’t wait for approvals. On average, 25% of patients are hospitalized while waiting for prior authorization, 19% experience life-threatening events, and 9% experience disability, permanent bodily damage, or even death. Moreover, 70% of current prior authorization relies on manual labor, which places incredible strain on administrative employees. For this reason, a whopping 93% of physicians say prior authorizations leave them with a high or extremely high administrative burden. So how can we solve this problem?
Recently, AI-powered authorization automation technology has come into the fray and simplified the human interaction required for prior authorizations. Firstly, they retrieve the required patient data and call insurance payers to check if prior authorization is required for the proposed procedure. Then, it automatically reads the patient’s medical documents and validates that the patient meets prior authorization guidelines. Next, it prepares the PA request and submits it through the provider’s portal and continually checks the status of the request so that a human doesn’t have to. Then, upon approval, this AI technology updates the medical records with the approved documents.
The benefits of this workflow speak for itself. Orbit AI-powered prior authorization process automation, for example, saves providers an average of 60% of all their existing costs and over $449M in cost savings. It does this by reducing costs by up to $9.60 per authorization while taking less than 5 minutes to complete the prior authorization process. It also fully automates around 82% of the PA process, meaning your team has up to 12 hours freed up, per member per week. Regardless of what services your healthcare office provides, it can vastly benefit from the inclusion of AI automated prior authorizations. Regardless of whether you want more time for patients or a quicker turnaround for prior authorizations, AI prior authorization automations have a way to benefit you.
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