Intelligent PMs help ensure prior-authorizations are in-hand by appointment-times.Everyone loves to hate prior authorization. Patients resent it because it can stand between them receiving quality care quickly and on their terms. Physicians tire of it because they have to justify treatment and medication to insurers, which often involves sitting on hold when they could be helping other patients.

An insurer is just about the only healthcare stakeholder that doesn't have reason to detest prior authorization since it's a strategy for managing medical costs.

Love it or hate it though, prior authorization is a key component of physician compensation at any practice. A recent survey by MGMA found that prior authorization requirements have increased for 86 percent of medical practices in 2018. Twelve percent said it stayed the same and only 2 percent said it decreased.

The bottom line is that prior authorization is fundamental to physician compensation and quality patient care. Failure to secure it in a streamlined manner can ultimately cause workflow inefficiencies, frustrate patients and staff, and potentially take a bite out of revenues.

Understanding the Full Scope of the Problem

Specialty practices are familiar with the basic requirements of a health management organization (HMO): Patients need a referral from a primary care physician before they can consult a specialist, and many medications and treatments need prior authorization from the payer. This also applies to many Medicare Advantage patients. According to the Kaiser Family Foundation, 63 percent of enrollees in the program were in HMOs as of 2017. It's also worth noting that enrollment in Medicare Advantage HMOs increased by 600,000 last year.

Furthermore, it's not just expensive or rare prescriptions and treatments that require prior authorization anymore. Common and affordable medications, for example, need to be cleared with payers with much greater frequency than in the past, according to the American Medical Association. Consider this testimony from one physician working at a urology practice:

"When I started here, the only procedures requiring prior authorizations were surgeries," wrote Robin S. "Now medications, radiology and in-office procedures require prior authorization, or you do not get paid."

Specialty practice revenues are particularly affected by prior authorization. However, all healthcare providers have in some way been impacted, and not necessarily for the better. According to a survey by the AMA, 84 percent of practices see prior authorization as a "burden" on physicians and staff. Consider some of the outcomes associated with failure to address these burdens, per the AMA's findings:

  • 92% of practices have reported care delays stemming directly from prior authorization tasks.
  • 78% of practices said prior authorizations can lead to abandoned treatment.
  • 61% have said that prior authorization can have a "significant negative impact" on clinical outcomes.

Clearly, then, it's not just revenue that's at risk for practices; it's also their ability to provide quality care – and as value-based care becomes more mainstream, the two become increasingly synonymous.

Granted, preferred provider organizations (PPOs) are more popular than HMOs. But even PPOs include aspects of managed care. These plans might not mandate referrals, but nearly all insurance plans require prior authorizations to be obtained for certain healthcare services.

Which brings us back to the question at hand: How can practices more effectively keep up with who needs a referral or authorization and for what services?

You Can't Avoid Prior Authorizations, but Your PM Can (and Should) Make the Process More Efficient

Prior authorization needs to be treated like referrals; that is, as a pre-appointment task. This was all but impossible until providers began implementing digital practice management tools.

In theory, PM software ensures the appropriate referrals or authorizations are obtained in a timely manner so that they can be attached to a claim prior to submission. This ideally happens before the patient encounter to avoid delays in prescribing medications or treatments. Patients whose prior authorization is checked off ahead of time don't have to wait as long for payers to provide the all-clear. The benefits here include:

  1. The opportunity for faster, and better, clinical outcomes.
  2. Reduced risk that your practice won't get paid.
  3. Fewer prior authorization-related abandoned treatments, which means better clinical outcomes and more revenue opportunities.

Your PM solution should allow you to set payer requirements by insurance in regards to the need for referrals and authorizations. However, specialty practices are all too aware that this is not as cut and dry as "certain patients or certain services always require a referral or authorization." Some payers may require a referral for an office visit and an authorization for specific services like surgery. Other payers might not require a referral for office visits but will demand a referral for special services like physical therapy.

A best-in-class PM solution handles payer discrepancies in a few ways. First, the PM predicts services and treatments that will be rendered based on each visit type and the patient's insurance plan. Ideal PMs should notify staff at the time of appointment creation or when reviewing office calendars via highly-visible colors and pop-up notifications that referrals or authorizations are necessary for the services that are scheduled. This helps ensure that all referrals and prior authorizations are in hand by the time treatment is prescribed.

AllMeds all-new PM not only provides helpful the notifications described above, but also allows your staff to manage multiple referrals and authorizations on patient accounts and allows the user to easily identify available referrals and authorizations to attach to claims. In other words, if prior authorization and referrals already exist, AllMeds PM makes sure your staff knows about them, and, better yet, doesn’t make them go digging for them.

The result: Expedited care delivery, better patient satisfaction and improved revenue collections.

Contact us today to learn how AllMeds all-new PM can reduce your prior authorization troubles and help your practice in many other ways, too.

Contact AllMeds today to learn how AllMeds all-new PM can reduce your prior authorization troubles and help your practice in many other ways, too.

AllMeds EHR PM RCM

Intelligent PMs help ensure prior-authorizations are in-hand by appointment-times.

AllMeds Specialty Practice Services

Intelligent PMs help ensure prior-authorizations are in-hand by appointment-times.

AllMeds Specialty Practice Services

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AllMeds EHR PM RCM

Intelligent PMs help ensure prior-authorizations are in-hand by appointment-times.

AllMeds Specialty Practice Services

Intelligent PMs help ensure prior-authorizations are in-hand by appointment-times.

AllMeds Specialty Practice Services