By Dennis Zanetti, NantHealth
The exchange of information between health plans and providers is often riddled with slow, tedious manual processes. Health plans incur significant costs to exchange administrative and clinical information, and often have no ability to close the loop with providers. As a result, patient care suffers, provider and member satisfaction declines, and payers lose out on meaningful reimbursement opportunities. By automating processes to better support bidirectional communication in vital clinical workflows, such as those associated with prior authorizations, both providers and payers can improve patient care while cutting significant administrative costs.
Here we take a closer look at the benefits automated prior authorizations can provide:
Why Automate Prior Authorization Workflows
Automating electronic prior authorizations is an important next step in healthcare technology. Securing prior authorizations are required for a diverse array of treatments, such as home health care, behavioral health, infusion therapy, high tech radiology, and a wide variety of inpatient emergent and outpatient procedures. Without automation, the process is cumbersome, time-consuming and costly.
Automated workflows can help prevent delays in patient care and eliminate associated administrative costs. It’s estimated that the commercial healthcare industry could save $9.4 billion by fully adopting electronic transactions for six of the most common claims-related administrative processes. Automating eligibility and benefit verification, the highest-volume transaction involved in electronic prior authorizations, represents over 40 percent of the total savings potential for the medical industry and offers the highest savings opportunities for both plans and providers. Leading health industry groups, including the American Medical Association (AMA), American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), and the Blue Cross Blue Shield Association (BCBSA), in a Consensus Statement recently concluded that automation and adoption of electronic prior authorization transactions is one of the top strategies to improve process efficiency in healthcare.
How Automation Works To Improve Efficiencies Without Disrupting Current Workflows
Technologies intended to improve the healthcare industry can often impede, rather than improve care and the business surrounding it. Instead of serving as obstacles to the way providers and plans currently work, automated solutions must bring both parties together and empower them by streamlining communication and enabling them to transmit clinical and administrative information in real-time. The right automated prior authorization solution, such as NaviNet Open Authorizations, a suite of workflows available on NaviNet Open, a secure, multi-payer-provider collaboration platform, enables health plans and providers to work together to deliver value-based care. The technology readily adapts to existing provider and payer workflows and technology by incorporating business logic and information exchange within the context of existing processes, such as verifying patients’ insurance coverage, determining whether an authorization is required for services, and sending necessary documentation as electronic attachments.
Automation also recognizes gaps, notifying providers where information is missing within their existing request, and makes it easy for them to upload supporting documents. It enriches communication by providing clinical summaries and medication lists and facilitates engagement in care management programs with tools, such as enrollment forms and performance reports, providing real-time access to critical information at the point of care.
The benefits automated prior authorization solutions provide include the following:
Automated prior authorizations can significantly reduce the multiple interactions usually required between providers and plans, saving them time and expense. For instance, it enables a plan to request information from a provider and prompts a provider to deliver the information electronically. An automation tool coordinates the workflow and provides a consolidated view of the case that combines the information submitted by the provider with responses from the health plan. The automated workflow also can deliver updated processing status from the plan and offer real-time authorization details.
To create even greater efficiencies, automated prior authorizations like NaviNet support clinical attachments. This enables users to submit a request and subsequently submit supplemental documentation critical to the review by tagging attachments with specific data attributes that make it easy for the plan to associate the attachments with the original request. These electronic workflows reduce and often eliminate unnecessary back-and-forth between parties, reducing the burden and costs for the provider and health plan.
It’s often difficult for providers to understand what data is required when submitting an authorization request due to the wide range of services and supplies that require prior authorizations. Policy requirements, too, vary by health plan and product, making it even more complex for providers to understand requirements. An electronic solution can collect the data that is required for each type of service request and send the data to the health plan for review. Collecting data appropriately creates a more positive user experience for the provider and makes processing by the plan more efficient.
Automated workflows enable plans to implement business rules in their electronic solutions that can help ‘pre-process’ authorizations and determine if a prior authorization is even required based on the details submitted. It also can provide automatic approval for simple requests. In cases where requests are standard, business rules are straightforward, and review is not necessary, providing a result to a provider in real-time without delay.
Conclusion: Automating Payer-Provider Workflows Is A Win-Win
Payer-provider workflows, such as those involved with securing prior authorizations, are historically cumbersome, often requiring multiple interactions that take time and add expense to healthcare. By leveraging technology to automate the workflow and streamline associated processes and communication, payers and providers can better align their objectives and ultimately deliver better care for patients, faster and more cost efficiently.
About The Author
Dennis Zanetti is the Principal Product Manager for NaviNet Open Authorizations and Claim Management at NantHealth and has been delivering technology solutions to healthcare payers for over 20 years.