Automating Prior Authorizations–It is a must and not a want!

Automation has proven successful for other essential healthcare administrative processes, providing momentum for ongoing efforts to improve and automate the preauthorization process so that it is more efficient and uniform. This will promote greater adoption of federally mandated electronic Health Insurance Portability and Accountability Act (HIPAA) standards, as well as emerging standards. The Centers for Medicare & Medicaid Services (CMS) has implemented the Council for Affordable Quality Healthcare / (CAQH / CORE) standards in their Medicare program, which encompasses eligibility and benefit verification, claim status, claim payment, and remittance advice. The secretary of Health and Huaman Services (HHS) has designated CAQH CORE as the authoring entity for federally mandated rules regarding Section 1104 of the Patient Protection and Affordable Care Act (ACA). According to (Health Care Registration; New York Vol. 28, Iss. 12,  (Sep 2019): 5-10.) There are barriers to automating the preauthorization process include:

1. Lack of consistency in data content
2. Lack of mandates for attachments/clinical documentation standard
3. Lack of clinical and administrative systems integration
4. Limited vendor products that support the standard transaction
5. State requirements for manual intervention
6. Lack of provider awareness

The American Medical Association (AMA) recently surveyed its members about the preauthorization process:

1. 65% report waiting for at least one business day for a preauthorization response from health plans;
2. 26% report waiting up to three days.
3. 91% report their patients’ care is delayed due to preauthorization processes, with
4. 11% reporting that care delays are always the case,
5. 36% report care delays often result and
6. 44% say patient care is sometimes delayed.
7. 75% say prior authorization can lead patients to abandon treatment.
8. 28% report prior authorization requirements led to a serious adverse event for their patients.
9. 88% say prior authorization burdens have increased in the past five years.

Efforts need to continue to automate the preauthorization process.  This will fee up time for providers and administrative support personnel to provide quality care to patients with transparent pricing.  There will continue to be barriers in the coming years due to constants change and slow to respond government regulations. Automating Prior Authorizations–It is a must and not a want! My Staffology has written on additional topics on Healthcare on Prior Authorization, we encourage you to click the link below.