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How the Prior Authorization Process Tests Patients, Providers, and Profits

ZOLL Data Systems | Aug 30, 2023

The prior authorization (PA) process was created as a utilization management tool for insurance companies and patients. However, it has oftentimes created heavy administrative loads, including increased claim denials, delays, and rework. This has created a burdensome environment for billing teams and financial impacts for providers. Manual processes require admin staff to constantly search through paper documentation, payer web portals, and more time-consuming work.

Current procedural terminology (CPT) means providers must track down specific codes associated with PA that then needs to be frequently followed up on when the final claim is submitted. Resolutions could take days to months on end, depending on the complexity or requirements stipulated by the payer. All of these delays can lead to patients foregoing care, cause burnout for healthcare workers, and can lead to partial or no reimbursement if the PA is not determined, for example, until after treatment has been completed.

Real-Time Technology is the Answer

Implementing a best-in-class PA tool to automate the manual tasks associated with the PA process can give doctors and other healthcare staff back their time to focus on patients. Procedures requiring PA are only expected to grow in the future, so reducing these manual tasks and the need for constant follow-up can mean better operational and financial performance in the long run.

Some of the capabilities provided by best-in-class PA technology include:

  • Master patient indexes (MPI) to identify patients
  • Direct, real-time connections to payers
  • An extensive library of payer rules that synchronizes eligibility
  • Integrations with electronic health records (EHR), laboratory information management systems (LIMS), health information system (HIS), and revenue cycle management (RCM) solutions
  • A self-learning, artificial intelligence (AI) system that dynamically updates automated workflows and rules engines
  • The ability to automatically validate a PA request, submit it, and receive instant decisions.

The PA process is complex, and streamlining these workflows means patients are able to access their care faster, plan for their co-pay or out-of-pocket responsibility, and reduce additional, unnecessary hospitalizations. To learn more about streamlining the PA process and how to evaluate PA technology, read the full article: It’s Time To Streamline the Prior Authorization Process, Protect Profits, and Improve the Patient Experience.

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