What to know about Prior Authorization Software
Simply put, Prior Authorization is a process that is required by insurance companies to know if a prescribed service or product will be covered. Ultimately, with this process, you’ll know whether the service or product requires an authorization and once approved, the provider can proceed with the order and qualify to receive reimbursement from the payer.
Prior Authorization is many times used for numerous procedures, imaging, injections, PT, DME and specialty medications before they are ordered for the patient. However, as you can easily understand, it creates a bottleneck. Here’s a simple example. Your physician places an order in the system and before that procedure can take place, it sets of a series of actions. Those actions are extensive causing your staff to provide several manual functions like visiting Insurance websites, faxing documents, calling them direct and sitting on hold for up to 30 minutes before they even schedule your visit.
It’s important to keep in mind that when you are using a prior authorization software, you won’t be simply saving your time and your patients’ time, now it will decrease the wait time and getting patients scheduled quicker ultimately providing better patient care.
Overall speaking, traditional (manual) prior authorization has many pain points. The most common ones include administrative burden, delay of care, high rates of denials, lost revenue, and excess labor.
The Best Ways to Utilize Prior Authorization Software
Before you pick just any prior authorization software, it is wise to do your research about the prior authorization company. This way, you’ll be saving some headaches since not all these companies are the same.
- Do they have a focus in your specialty?
- Can they interface your system to the Prior Authorization System?
- Does your PHI ever go offshore by using their people or products?
- Do they offer a free analysis workflow which help them understand your business?
- Is the solution they are offering really technology or is a bank of people behind the scenes doing the manual labor for you?
- Is a rules engine provided that allow you to customize your needs to your specialty?
As you start using the prior authorization software, you need to ensure that you are using it in the best way in order to maximize time.
1: Set a post live weekly call with your Prior Authorization company:
As you go live with your Prior Authorization solution, it’s imperative that you have in your contract post live implementation support. This allows you to tweak the rules engine to your needs, assist any user training, and make any modifications to the setup of the program.
2: Denial Reasons:
The system should be able to track the progress of your Authorizations from ordering to approval. It’s important that you have a scheduled process with your vendor to also work these daily or weekly and to see if any denial trends are occurring and add them as new rules so you can decrease the denials before they even run.
3: Three Month Check-up
After the first three months, start running reports to manage the business such as:
- Has my labor requirements decreased and can I repurpose that labor into other areas that it is needed
- Can I change my policy to now get patients scheduled sooner now that the system is automating a big portion of work and it’s returning back faster results?
4: Moving over to Support
Always report any issues you may run across immediately to your vendor, as they should be able to address it with rules engine modifications or if the Insurances processes have changed. Reporting these challenges with help your Prior Authorization process run smoother.
Bottom Line, the prior authorization solution will provide an organized approach in your facility. It will reduce your labor efforts, your denial rates, your rescheduled or missed authorizations, all having a positive impact on that lost revenue occurring today in your facilities.