How Long Prior Authorization Timelines Impact Payer CFOs

In an on-demand world, the idea of waiting several days to get approved for a procedure or medical treatment can be frustrating for patients, especially in an on-demand world where almost everything we need is available with a click or a swipe. The technology is available for on-demand prior authorizations (PAs), so the old way of doing things just doesn’t cut it anymore. Not only is instant prior authorization more convenient for patients and providers, it’s also safer and provides better overall outcomes.

Welcome to the 21st Century, Medicine

The internet—and more recently the smartphone—have created an on-demand economy where we can get anything we want with the touch of a button. From food and groceries delivered to our doors in minutes to new-release movies premiering in our living rooms, we’ve gotten used to instant gratification.

Medicine and patient care are (slowly) shifting to meet these demands with services like:

• Online scheduling
• Patient portals
• Online lab results
• Telemedicine appointments

Unfortunately, payments have not kept pace with the technology-fueled speed and accuracy of patient care. Instead, clinics and providers use 20th-century technologies to communicate with payers to get authorization for treatments based on insurance coverage and plan requirements.

Clinic staff may have to send a fax, make a phone call, or even mail documentation to the insurance payer to provide more details about a procedure or justification for why it’s medically necessary. This delays treatment, which is frustrating but also dangerous.

Providers know the wait for PAs is not good. In a 2020 provider survey by the American Medical Associationopens in a new tab:

• 94% reported delays in care because of prior authorizations.
• 90% said prior authorization has a negative effect on their patient outcomes.
• 30% have seen adverse events that were the result of prior authorization delays.
• 21% reported that their patients were hospitalized because of prior authorization delays that prevented necessary care.
• 79% said prior authorization waiting periods can lead patients to abandon their course of treatment.

While this might be the norm in medicine, it’s doesn’t have to be. We have the technology to improve these processes long term.

How Electronic Prior Authorization Benefits Payers

The harm to patients from long prior authorization wait times is well documented, but patients are not the only ones who would benefit from shortening the time for prior authorizations. Payers can also realize significant improvement with tools that help:

• Reduce total cost of care:Technology that improves care outcomes can lower reimbursement rates and improve PMPM expenses in high-cost patient populations over time.
• Improve efficiency: Processing prior authorizations manually is time-consuming for employees. It increases overhead costs when employees engage in repetitive tasks that advanced AI and machine learning software could easily do.
• Streamline your technology: Antiquated technology systems often don’t work well together. This adds more inefficient manual processes to your workflows, and makes it hard to capture data insights from your software.
• Improve provider relations: Instant prior authorization with PINC AI™ from Premier helps you eliminate communication breakdowns and barriers that can be costly for both sides.

Instant Prior Authorization is Possible with the Right Tools

Prior authorization, like many other aspects of medical care, could be easier and faster with the right technology tools. Rather than wasting staff and provider time on the phone or faxing, prior authorization should be electronic and immediate. It’s not a far-off dream scenario either, because the technology exists today to make it happen.

Electronic prior authorization (ePA) with PINC AI™ Clinical Intelligence harnesses the power of data for on-demand results. It can:

• Bring together EHRs from multiple vendors.
• Integrate with payer adjudication systems.
• Create and implement decision trees based on available information and payer policies.
• Use natural language processing and machine learning to determine the right outcome.

The system takes the information and provides an immediate prior authorization decision—in minutes, not days—through a cloud-based software system. Both the provider and patient get peace of mind and can move ahead immediately with treatment plans.

How ePA Works

Using ePA with PINC AI™ Clincal Intelligence from Premier is simple. First, the physician places the order, which triggers a cloud-based engine decision. The system gathers all the necessary information about the insurance plan and treatment to approve or deny prior authorization. Next, the system checks for medical necessity. If there isn’t enough information, it will prompt you with additional questions. This level of clinical decision support helps providers quickly move through the steps to get a PA.

With ePA with PINC AI™ Clincal Intelligence, most prior authorization approvals can take just a few minutes. The physician gets an authorization number that the patient can take with them and use in the billing and claims submission process.

For the small number of prior authorizations that cannot be approved instantly, the physician will then have to follow the traditional channels for obtaining authorization from the payer for reimbursement.

A Better Way to Get Prior Authorizations

With the technology available to speed up prior authorizations, there’s no good reason to continue doing things the old way. Learn more about how ePA can reduce the total cost of care, bring down PMPM expenses, streamline workflows, and improve provider-payer relationships. Download our E-book today to find out how PINC AI™ Clinical Intelligence makes it possible.