This is part 3 of a three-part series on how to improve the prior authorization process. Part 1 covers the impact of prior authorization, and part 2 explains why they are necessary. This final part reviews the steps you can take to make prior authorizations easier.
The reality is that abolishing prior authorization is unlikely, but doctors and their patients are experiencing negative impacts due to the current process. Doctors and payers need to find a way to overhaul this process – which will likely take years. However, there is hope. Doctors can take steps to adjust practice operations immediately to simplify this (and work with a prior authorization specialist to implement it all).
Doctors and their staff have undergone years of training to prepare them to determine the right course of treatment. Many physicians firmly believe taht they should be trusted to make these decisions based on their credentialing process and ongoing medical education training. While these prior authorization systems won't be eliminated, significant reform can devolve them back into the edge case verification processes they were initially created for.
The ultimate solution to prior authorizations involves payers and providers working together to create a system that allows approvals based on provider metrics.
Physicians who show a track record of expertise through practice data metrics, such as diagnosis tracking and outcomes, should be able to establish streamlined processes with payers to receive approvals instantly. Openly sharing this data can show payers what providers are doing and how they're doing it to create a level of trust that gives them gold card status—if not for all procedures, then at least most of the standard procedures their specialty bills for. This would take us back to the original process for prior authorizations and save the administrative workload and resources while protecting patients.
The good news is that while the legislation is still in its infancy, five states have passed laws for some form of gold carding program - with 13 more in the works.
The bad news is that it still leaves most states without these programs and a long journey ahead to get the required buy-in from critical stakeholders.
However, there are things your practice can do to take steps in the right direction.
Creating the gold-card standard of prior authorizations will not be easy. Establishing this level of trust between providers and payers requires accessing and understanding data from disparate systems, which many independent practices find challenging when they are outside a larger healthcare organization. So, that's the first step: building the structure for internal data gathering beyond a practice's EMR. It is imperative to have access to and understand data from RCM and billing data systems. Next is creating systems that support bidirectional data flow with payers. The time to start building out this infrastructure is now. Practices that have this data available first will be able to reap the benefits of optimized prior authorizations.
It's time to build your internal data infrastructure to strengthen your relationships with payers, streamline prior authorizations, and reduce administrative headaches.
The next step is to build upon those upgraded practice processes to support value-based care and bundled payment programs. These care models are designed to create provider accountability for the cost and quality of patient care and reduce the incentives for overutilization and low-value care—both critical goals of prior authorization.
Unfortunately, setting up value-based programs is not easy. It requires building out tracking systems to understand and evaluate value.
In some cases, physicians have suffered or lost money with value-based care and have returned to utilizing fee-for-service contracts.
By implementing value-based programs, practices have an opportunity to not only have a better understanding of their internal metrics and processes but also reduce the need for prior authorizations. In coordination with payers, practices could identify specific drugs, procedures, or services and agree to eliminate prior authorization based on agreed-upon terms. These terms could include quality measures, performance benchmarks, or demonstrating adherence to evidence-based clinical pathways. Another option is to condense prior authorizations into one approval for an entire episode of care. This allows for a single prior authorization to be approved for a preset care process, or as we refer to it, a clinical care pathway.
Ultimately, these types of programs require cooperation between providers and payers and coordination between networks of providers willing to partner and create these clinical care pathways. Coordinating these physician-developed care plans and protocols helps streamline care and reduce costs.
To make this happen, practices need a better understanding of how they can market themselves to referral partners and payers. It comes down to practices needing to:
Value-based care programs and bundled payment models are ideal drivers for getting practice metrics in order, coordinating care, and providing data to demonstrate the reduced need for prior authorization.
If you feel like prior authorizations are weighing down your practice, you can start by working with an expert who can reduce administrative burden. As with every process within your practice, there are pros and cons to outsourcing:
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· Increase speed: When you hire a dedicated team to handle prior authorizations, you know that's all they're going to be doing. Instead of managing all the other admin tasks within your practice, an outsourced team can focus on completing the prior auth tasks correctly. · Gain expertise: An outsourced team has experience with (and insight into) other practices' prior authorizations, so they are more likely to understand the nuances of what it takes to process an authorization. · Reduce errors: Having additional expertise and established processes also helps reduce errors when dealing with ever-changing processes and the inconsistencies between different payers. An outsourced team has more resources to stay up to date on changes occurring across every payer. · Decrease operating costs: Some practices have so much prior authorization churn that they have to hire additional employees to handle the workload. Investing the time, money, and resources on a new employee doesn't necessarily make sense. |
· Increase direct costs: Depending on your specific practice, hiring an employee may cost less in direct costs than paying an outsourced company. The right partner, however, should not handle the prior authorization process in a vacuum. They should look at your overall revenue cycle management (RCM) processes holistically by analyzing data to identify bottlenecks, suggesting operational improvements, or implementing best practices that reduce denials and improve cash flow overall. · Surrender control: Giving up control is the hardest aspect for independent practice owners to accept. Outsourcing processes such as prior authorizations does mean that your practice hands over the reins. However, the right partner will make the process fully transparent, giving you direct access to the entire process, providing real-time communication, and sharing insights into exactly how the prior authorization process is going. |
If you decide to outsource, make sure you find a partner that delivers the services you need and provides the transparency and reporting needed for you to effectively evaluate their performance.
The key to alleviating the prior authorization struggle is harnessing your data and then putting it together to tell the story that you want to effectively market to payers and referral providers. Whether you're ready to take the full leap in preparing for gold carding, are just getting started digging into your metrics, or just want to get it off your plate, TRIARQ can help.
Building a robust data infrastructure is the first step in improving prior authorization processes. Our team has an arsenal of tools to build a custom solution that fits your practice's exact needs. Once the data flows are established internally, we can build out the interoperability requirements from CMS and position you to take on any additional requirements from them or other payers.
This data will then be leveraged to uncover the metrics that matter to build a strategy to take on risk, market your practice to referring providers and payers, and ultimately solidify your independence.
The payers are already evaluating you. Instead of waiting for them to grade you, build out your data infrastructure to take control of the narrative and create the compelling marketing story that your practice wants to tell.
The proper data infrastructure makes it easier to examine long-term data trends within your practice and see how you compare to similar practices. We help uncover the details of why your prior authorizations are approved or rejected, dive into the metrics that payers use to grade you, and more. Ultimately, access to this level of data, coupled with our team of experts, makes it possible to fully understand how your practice is performing—even beyond prior authorizations.
Because we work only with independent specialty practices, we have a bird's-eye view of what's happening within other similar practices and the healthcare industry, so we understand the struggles you're facing and know precisely what practices like yours need. We leverage our expertise to help you across all components of practice performance management, not just prior authorizations. We can help optimize workflows and processes, reduce denials, and meet cash flow budgets. In addition to helping improve prior authorizations, we can help you:
Though prior authorizations can't be avoided, providers can take action today to leverage practice data and put them in an attractive position to payers looking for value-driving partners and prior authorization specialists. By partnering with the right team of experts, you can uncover the metrics that matter most within your practice to improve day-to-day operations and be proactive in building a practice that is attractive to payers and referring providers.