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Blog | Mar 29, 2023

Intelligent Automation for Provider Prior Authorization

healthcare prior authorization automation
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Across healthcare, the number of procedures and medications now categorized as high risk – and therefore requiring prior authorization – is rapidly rising. Payers are far more stringent about patient eligibility for benefits as they focus on increasing revenue.

There is now a pressing, medical necessity for healthcare providers to speed up the steps of the prior authorization process for procedures and medications. It’s not only essential for them to deliver on their objectives around enhanced patient care and valuable patient experience; it’s also vital to optimize capacity, realize an increase in cost efficiency and generate much-needed revenue as capacity advances.

Challenges for Healthcare Providers

The authorization process begins when a clinician first determines a course of action for a patient, whether that’s medication, lab testing, treatment plans, or a clinical procedure. Medical assistants must contact the health insurers with authorization requests for benefits verification and/or to access payer policies to check medical codes against the list provided by the health insurance company.

Manual processing

Authorization is a highly manual process, often involving a lot of back and forth between the medical assistant and the payer’s organization. We’ve seen instances where medical assistants spend up to six hours on the phone with a contact center trying to ascertain whether a procedure’s authorization approval has been received.

On average, it takes eight to 10 days for providers to get authorization for high-risk procedures and medication. These eligibility issues can delay patient treatments and medications, making it harder for providers to optimize capacity and keep cash flowing into the business.

Cost implications

There is also a huge cost implication associated with manual workflows. These administrative burdens reduce operational efficiencies, creating a backlog of work for administrative staff. The provider network is stretched thin, having to deploy large teams to push authorization submissions to payers, then more time from billing teams further down the line if authorizations are missed or denied due to human error.

Errors and missed authorizations

Another unfortunate consequence of inefficiency within the authorization process is unwanted shocks for patients, where authorizations are missed by providers so patients receive unexpected bills for thousands of dollars worth of medications or services.

Payment disagreements

The CMS No Surprises Act now mandates greater transparency around healthcare costs and the removal of patients from payment disagreements between their healthcare providers, healthcare facilities, and health plans. But many existing authorization requirements make it very challenging for providers to meet these new clinical guidelines.

Prior authorization requests

There are many instances where doctors change prescriptions to avoid a labor-intensive and lengthy authorization process. For example, when a patient is fitted with a pacemaker and taking a time-release medication to support their heart condition, the doctor might change that prescription if it now requires them to make prior authorization requests to payers. To avoid delays or denials, a patient may end up with a different medication – one that doesn’t require authorization or is cheaper, but which can negatively impact their health or lifestyle. 

Optimizing healthcare revenue cycle performance with intelligent automation
Optimizing healthcare revenue cycle performance with intelligent automation

Why Is It Called Prior Authorization?

Prior authorization is when authorization is needed before care can be given. Payers and laboratory benefits managers implement checks and balances to assess the medical necessity and cost of certain patient care and whether the payer will reimburse the provider for that procedure.

The idea is that prior authorization is a less expensive approach to patient care, but the ramifications are that healthcare providers are inundated with more paperwork, which siloes time that could be spent on patient-facing tasks. Plus, without automation, prior authorization is a lengthy process, causing patients to wait even longer for the care they need.

How and Where Do You Automate Prior Authorization?

With intelligent automation (IA), providers can dramatically reduce the time it takes to secure authorizations while also reducing costs. IA is an artificial intelligence (AI) technology including machine learning (ML) and robotic process automation (RPA) to automate work.

In the healthcare industry, IA can be used to optimize authorization workflows, ensure a reduction of claim denials from health insurers, relieve common patient access challenges, speed up patient registration, and automate critical revenue cycle tasks to reduce administrative costs and allow staff to focus on higher-value work requiring human intervention, such as spending more time with patients to create a more positive experience.

Electronic Health Records (EHR)

An electronic health record (EHR) is a great example of how automation can help a healthcare organization improve workflow and patient experience. EHR is a digitized version of a patient’s health chart. It contains real-time access to patient records, kept in a secure environment to ensure only authorized users have access. EHRs contain medical and treatment history, as well as a broader view of a patient’s care to better streamline provider workflow when making medical decisions and treatment plans.

First assessment

Critically, automation can kickstart the authorization process at the initial point of service when clinical staff first assesses a patient and all the steps afterward. A digital worker can immediately check the recommended procedure or medication against the relevant payer’s database, or by logging into the payer’s portal.

Checks and updates by digital workers

Where prior authorization is required, a digital worker can complete the necessary applications, locate any gaps in documentation, perform eligibility and benefit checks, and provide all required clinical documentation for creating or updating a patient’s EHR. Plus, digital workers perform in real-time, 24/7, giving staff more time with patients, increasing authorization accuracy rates, and lowering denial rates.

With most prior authorizations now being processed through Availity, digital workers can log onto the broker site, apply for the relevant authorizations, and continually make status checks in real time for eligibility updates. They can then flag medical assistants or clinical staff with questions or with any additional documentation requests and alert them when an authorization is approved or denied.

Not only that but when this faster electronic authorization is granted, the digital worker can then immediately schedule the relevant appointment or lab test and send a prescription to the patient based on the set clinical requirements. This rapidly speeds up the time it takes for patients to get the care and medication they need, while also enabling hospitals and clinics to maximize their usage of operating room capacity.

Examples of automated prior authorization

Already, healthcare providers bringing in some level of authorization automation to their processes are reducing times for high-risk authorizations from eight to 10 days to four to five days. And if they continue to progress with their intelligent automation, this timeframe will decrease to 24-48 hours once the process is fully automated on both the provider and payer sides. In some cases, we’ll see instantaneous authorizations for high-risk procedures and medications within a fully automated process.

Similarly, when it comes to non-elective surgery, patients typically wait up to four weeks for procedures and much of this time is down to manual authorization processes. Through automation, some providers are already cutting this timeframe to two weeks, drastically improving entire patient access workflows so patients can get essential medical care faster.

Transforming the Revenue Cycle

Healthcare providers have an expanding need to accelerate their automation plans. Stretched resources and soaring complexity across the revenue cycle are exposing the limitations and inefficiencies of paper-based and manual processes. The hospitals and clinics already adopting automation are far better placed to cope with dramatic fluctuations in demand.

This is why we’re now seeing a significant surge in providers looking to implement IA and healthcare RPA into their front and back-office processes. IA ensures a decrease in workload from manual tasks. Already around half of the providers are initiating some level of automation into their revenue cycle workflows, and we expect that figure to rise substantially.

Intelligent automation with SS&C Blue Prism

The reality is that most providers are still struggling with a backlog of authorizations and manually meeting those authorization requirements is no longer an option. Luckily, SS&C Blue Prism has flexible choices with our optimized intelligent automation solutions.

IA is hugely attractive because it can be up and running within days and scaled according to business needs. Digital workers can operate 24/7, carrying out repetitive, data entry tasks with far greater speed and accuracy than human workers, and they can be deployed anywhere across the organization to clear backlogs. They provide a flexible and intelligent pool of resources, which can tackle the most important operational pain points within a hospital or health system, providing patients with authorizations in the record – and often lifesaving – time.

Our experience shows that a provider turning over $1 billion annually in patient revenue can save as much as $1.3 million per year just by automating their claims authorization process. And these savings can be multiplied several times over when automation is introduced more broadly across the revenue cycle.

Benefits of intelligent automation in healthcare

Importantly, we’ve seen how IA can galvanize existing workers who are often fed up with the sheer amount of time they’re spending doing mundane tasks and repetitive work. With digital workers alleviating the burden for providers and authorizations, employees are freed to focus on more rewarding and higher-value activities, which can make a real difference to patients and the business. This leads to marked improvements in employee well-being, engagement, and retention – all of which help boost overall productivity for the business.

The current groundswell we’re seeing around IA among providers large and small will completely transform revenue cycle management over the coming years. Agencies with requirements like the American Medical Associations (AMA) and CMS include massive numbers of medical codes needing to be maintained; IA helps you stay up to date on these changing codes and documentation requirements, and payment methods are much easier, more accurate, and faster.

The future of prior authorization

It’s highly likely that by 2027, the entire end-to-end authorization process will be automated. Hospitals and clinics will no longer need medical coders; they’ll rely completely on digital workers for handling authorizations, confirming patient care plans, verifying eligibility, and performing patient access checks with accuracy and speed.

Providers should be looking to get ahead of this trend, automating their authorization processes as part of a broader, long-term strategy for intelligent automation within revenue cycle management workflows and across the wider organization. Those who can introduce digital workers effectively and sustainably will be well placed to streamline their authorization processes and, in doing so, enhance patient experience and drive revenue.

To learn more about healthcare automation and how it can benefit your healthcare organization, read our comprehensive guide, or listen to our podcast episode where we discuss intelligent automation improving revenue cycle management.

Optimizing healthcare revenue cycle performance with intelligent automation
Optimizing healthcare revenue cycle performance with intelligent automation

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