Reboot Your Revenue Cycle: Get Proactive with Prior Authorization Automation [HFMA Webinar Key Takeways]

December 16, 2022

Despite forward momentum by Congress to address the prior authorization (PA) burden, healthcare providers typically still rely on a mostly manual process prone to errors. In a recent HFMA webinar, David Mistkawi, VP of Access Management Solutions at The SSI Group, LLC (SSI) and Tyler Wince, Chief Product Officer at Myndshft, discussed the critical need for improving the prior authorization/pre-certification process and why automation is such a game changer.

Here are the key takeaways:

Prior Authorization is a Problem Worth Solving

The inefficiencies inherent in manual prior authorization processes and workflows make it the most time-consuming transaction for providers, with ninety-five percent of hospitals and health systems reporting increases in staff time spent seeking prior authorization approval. It also has the highest cost transaction across the industry and is one of the leading causes of denials.

The Status Quo is Falling Short

Today’s prior authorization or pre-certification process relies on inefficient and error-prone manual efforts using phone, fax, and web portals. It lacks the efficiency and accuracy needed, especially given the ongoing workforce challenges in healthcare. Additionally, and maybe most importantly, the manual process creates bottlenecks in the patient care journey, making it a patient safety and satisfaction issue. Nearly all provider care delays are associated with inefficiencies and administrative issues with current prior authorization.

Now is the Time to Fix Prior Authorization

Shrinking margins and workforce labor shortages are causing hospitals to re-evaluate areas to help save time and money – and prior authorization is at the top of the list. Additionally, new government regulations are coming into effect, and others are being introduced with greater regularity. For example, the proposed Interoperability and Prior Authorization Rule builds on the CMS Interoperability and Patient Access final rule, adding new provisions to increase data sharing and reduce overall payer, health care provider, and patient burden through proposed improvements to prior authorization practices. Industry initiatives, including HL7 FHIR APIs and the DaVinci Project, also include use cases for prior authorization.

Short-term Fixes Can Help, But Automation is the Real Game Changer

Training, creating a PA or pre-certification triage role, centralization, and building payer relationships are all short-term fixes that can provide tangible results. However, organizations will only see long-term efficiencies and value from automation. Automation with bi-directional, real-time data connections enables faster patient care, less manual work for providers, near real-time access to PA decisions and coverage requirements, better health outcomes from improved care access, and elimination of adjudication delays.

Top Things to Look for in Prior Authorization or Pre-certification Software

Not all PA software is equal. If you are looking for a system that produces the tangible results mentioned above, you need a software system that:

Has a payer policy library and rules engine to enable a quick determination of whether PA is required and the criteria necessary for a clean submission, along with selecting the appropriate submission form.
Is a comprehensive enterprise-wide solution that covers anything under medical benefits, including inpatient/outpatient, acute/post-acute, specialty drugs, and infusion, physical, occupational, and speech therapies.
Provides automated data exchange for secure, seamless access to payer, provider, and patient data combined with intelligent automation to eliminate mundane data entry.

For more insights from the webinar, please click here to listen on-demand.

About SSI Prior Authorization

SSI Prior Authorization is a hospital enterprise-wide solution with 700+ real-time payer connections that covers anything under medical benefits, including infusion, physical, occupational and speech therapies. 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.