The healthcare industry faces a constant challenge: balancing rising costs with the imperative to deliver high-quality care. Prior authorization has become a crucial tool for payers, helping to ensure medical necessity and control spending. However, the current process is often bogged down by administrative complexities, creating a burden for both providers and patients.
A 2019 JAMA study found that a staggering quarter of all healthcare spending could be classified as waste. While prior authorization helps rein in these costs, a staggering 88% of physicians report feeling overwhelmed by the administrative burden of processing authorization requests.1 However, there’s a solution waiting to be embraced: integrating prior authorization seamlessly within Electronic Health Record (EHR) workflows.
This blog post will delve into the transformative potential of embedded prior authorization. We’ll explore how leveraging open-source solutions and automating clinical data retrieval can unlock real-time authorization determinations, leading to a win-win scenario for healthcare payers and their members.
Here’s what we’ll cover:
- Efficiency & Cost Savings: Streamlined workflows and reduced administrative burden.
- Improved Member Experience: Faster approvals and a smoother experience.
- Effective Data Integration: Ensuring seamless information flow between systems.
- Choosing the Right Partner: Key qualities for a successful implementation.
Streamlining Operations and Reducing Costs
The current state of prior authorization is riddled with inefficiencies. Manual processes for requesting and reviewing authorizations are time-consuming and prone to errors. This translates into significant administrative burdens for both payers and providers, diverting valuable resources away from patient care.
Integrating prior authorization with EHR workflows represents a paradigm shift. By leveraging existing clinical data within the EHR, the process becomes automated. This eliminates the need for manual data entry, reduces the risk of errors, and streamlines the entire authorization process. The result? Significant cost savings for payers due to:
- Reduced administrative overhead associated with manual processing.
- Improved accuracy in authorization requests, leading to fewer denials and rework.
- Enhanced staff productivity through automation.
According to the 2023 CAQH Index Report, the adoption rate for electronic prior authorizations (ePAs) in the medical industry has increased by three percentage points, now standing at 31%.2 Despite this progress, prior authorization continues to be one of the most burdensome administrative tasks for providers, with significant time and cost implications. The report highlights that fully electronic transactions could save the medical industry approximately $494 million annually.
Enhancing the Member Experience
The benefits of streamlining prior authorization extend far beyond cost savings. For patients, the traditional process can be frustrating and lead to delays in receiving necessary care. Imagine a scenario where a patient requires a specific medication, but their provider’s authorization request gets caught in bureaucratic red tape. This can have a negative impact on the patient’s health outcomes and overall satisfaction with the healthcare system.
By enabling prior authorization within EHR workflows and ensuring payers can receive and respond to ePAs via data transmissions, real-time determinations become possible. With access to relevant clinical data at their fingertips, payers can make informed decisions quickly. This translates to:
- Shorter wait times for patients, ensuring they receive timely access to necessary care.
- A smoother and less stressful experience for patients, fostering trust and satisfaction with their healthcare provider and payer.
- Improved health outcomes for patients due to timely access to necessary treatments and medications.
Interoperability Standards: The Key to Seamless Integration
The true potential of EHR-integrated prior authorization lies in interoperability standards such as FHIR® (Fast Healthcare Interoperability Resources) and initiatives like the Da Vinci Project. These standards enable seamless data exchange between providers’ HER systems and payers’ systems, ensuring that authorization requests and responses are transmitted electronically, accurately, and efficiently.
Providers can generate prior authorization requests directly with their EHRs, leveraging the FHIR® and Da Vinci standards to send and receive information. This eliminates the outdated practice of dropping authorizations to PDF and eFax, which only perpetuates inefficiencies. Payers must be prepared to accept ePAs, as failing to do so will result in missed opportunities for automation and increased administrative burden.
The Importance of the Right Partner
The success of integrating prior authorization into EHR workflows hinges on choosing the right technology partner. A true partner understands the unique challenges faced by healthcare payers and their members. They bring not just the technology but also the expertise and ongoing support necessary for a seamless transition and long-term success.
Here are some key qualities to look for in a technology partner:
- Deep understanding of healthcare payer operations: They should possess a comprehensive understanding of the challenges payers face with prior authorization, including administrative burdens, member satisfaction, and cost containment.
- Proven track record in technology integration: Look for a partner with a history of successful implementations and a strong reputation within the industry.
- Commitment to ongoing support: A successful integration requires ongoing support and collaboration. Your partner should be invested in your long-term success and provide the resources necessary to optimize the solution and address any challenges that may arise.
Embrace the Future of Prior Authorization
The integration of prior authorization within EHR workflows represents a significant leap forward for healthcare payers. By streamlining processes, reducing costs, and enhancing the member experience, this innovative approach paves the way for a more efficient and patient-centered healthcare system.
At HealthAxis, we understand the complexities of healthcare payer operations and the critical role that prior authorization plays. We are a leading provider of CAPS technology, with a proven track record of helping payers achieve significant improvements in efficiency, member satisfaction, and cost containment.
In addition to our proprietary CAPS platform, HealthAxis offers strategic consulting services that adapt to any scale, ensuring organizations thrive. We empower our clients to optimize their technology and operations to meet their unique challenges. Our approach goes beyond simply offering technology. We build partnerships with our clients, working collaboratively to understand their unique needs and develop a customized solution that integrates seamlessly with their existing EHR workflows. We provide ongoing support and guidance to ensure a smooth transition and maximize the return on investment.
Schedule a discovery call today to explore how our CAPS solutions and strategic consulting services can help you transform your prior authorization processes and achieve your operational and financial goals. Together, we can build a future where prior authorization serves its intended purpose without sacrificing efficiency or member satisfaction.
Author:
Lisa Hebert
Senior Vice President of Product Strategy and Management
HealthAxis
Sources:
- Waste in the US Health Care System, JAMA Network
- 2023 CAQH Index Report, CAQH
