Prior Authorization FAQ for Healthcare Providers

February 21, 2023

As prior authorizations (PA) or pre-certifications continue to increase, many providers have questions about PA and how they can improve their own processes. Here are answers to the most pressing prior authorization questions asked during our latest webinars.

Why does the occurrence of prior authorizations seem to be increasing?

The volume of medical procedures and prescribed medications requiring prior authorization is increasing significantly, according to the American Medical Association. There are several factors involved in the increase, including care becoming more complex, care becoming more personalized and the challenge between the payer and provider who want to ensure that appropriate care is being provided. Value based contracting arrangements are also pressuring payers to put into place utilization management programs, which can sometimes limit services.

What are the differences between manual prior authorizations versus automated prior authorizations?

Today’s prior authorization processes mostly rely on inefficient manual efforts using phone, fax, and web portals. This current system is repetitive and prone to errors, often requiring hours of time-consuming detective work and manual data entry. Here’s what it typically looks like: communication between the physician’s office and the insurance company is necessary to determine if prior authorization is required and what criteria must be included in the submission. In order to receive approval, the prescriber may need to complete a form or contact the insurance company to explain their recommendation and the need for the particular service based on patient factors that are clinically relevant. The prior authorization is then reviewed by clinical pharmacists, physicians, or nurses at the health insurance company.

Automated PA, on the other hand, takes advantage of technology and aggregated patient, provider and payer data to streamline and speed up the process for healthcare providers, insurance companies, and patients. It involves using software to gather, process and transmit information about the requested medical treatment, insurance coverage and claim information. Once a PA submission is prepared, it is automatically pre-checked for errors or omissions and submitted via the specific payer’s preferred channel.

Since it requires minimal input, it helps reduce administrative burden and improve the efficiency of the process.

Can automated prior authorization solutions accept a 278 transaction to initiate the prior authorization process, or is there another way to get data into the prior authorization system?

 The 278 was a good transaction when it was proposed in the mid-1990s. As clinical care has become more detailed and complex, and prior authorization requirements increase, the 278 doesn’t have the ability to support all the information to effectively perform a clinical utilization management review. Not many clearinghouses support the 278 and only a handful of payers will do much with it. Because of the 278 transaction’s limitations, it will likely be superseded by more robust-data sharing options. Currently, CMS has proposed new rules and regulations to address the administrative burden of prior authorization.

As a result, you need a PA platform that is fully compliant with emerging standards and legislative fixes anticipated in the next few years that impacts both providers and payers.

Can an enterprise-wide prior authorization platform provide the requirements for a specific place of service?

Yes, the SSI Prior Authorization platform can provide requirements for a wide variety of places of service including ambulatory surgery centers, independent clinics and labs, inpatient acute settings, skilled nursing facilities and more.

How do the systems obtain and maintain insurance company authorization contact information?

Contact information is automatically pulled out of payer systems and published policies. The contact information is very detailed and is sub-divided by plan type, specific states and specific procedures.

Can you discuss the availability of requirements for FHIR (Fast Healthcare Interoperability Resources) standard?

The Fast Healthcare Interoperability Resources (FHIR) standard is a set of rules and specifications for exchanging electronic healthcare data. It is designed to be flexible and adaptable so it can be used in a wide range of settings and with different healthcare information systems. Most data today can be extracted using FHIR.

What examples of solutions have you seen that take into account the various levels of clinical specifics that may be required after the authorization has been approved? For example, cheaper, simpler procedures may have no clinical questions, while more complex procedures have an elaborate questionnaire.

Modern platforms can pre-populate basic information via a web portal or other interface, while more detailed questions often require more legwork by the user. There is new research and work being done with AI (artificial intelligence) that can parse the natural language of clinical notes and extract it into clinical diagnoses. We anticipate more AI supported technology in the future.

Is there a way to get a deeper dive into what automated prior authorization might look like in the context of our set of procedures we provide?

Yes, request a demo of our SSI Prior Authorization solution and we’ll get back to you about how we can best meet your specific needs.

About SSI Prior Authorization

Market changes are creating the need for a more advanced enterprise-wide platform – one like SSI Prior Authorization that connects in real-time to 700 payers and includes infusion, physical, occupational and speech therapies (anything covered under medical benefits). To see how it can help you reduce the complexity, costs, and time crunch of the manual PA or pre-certification process, learn more here or schedule a demo.