Prior-Authorizations

Sladjana Vukovic is RelateCare’s Director of Revenue Cycle Management. Previous to RelateCare, Sladjana worked for Cleveland Clinic in various Revenue Cycle functions: Financial Counselling, Scheduling, Registration, Authorization, and Denials Management. Sladjana performs detailed, quantitative analysis providing clients insights addressing healthcare’s biggest challenges with a core focus on increasing revenue and reducing costs.

The challenges and issues surrounding the prior-authorization process are, in my experience, often misunderstood aspects of the Revenue Cycle. An essential aspect of the patient access process, if not handled correctly the prior-authorization process can form a bottleneck that impacts both the timeliness of care given and the financial bottom line for many healthcare providers. In this article I explore some of these challenges and how we at RelateCare have developed a suite of solutions to overcome them and transform these challenges into opportunities.

WHAT ARE PRIOR-AUTHORIZATIONS AND WHY DO THEY MATTER?

When a patient is seeking a medical procedure, it is usually necessary for their insurance company to determine whether they deem it medically necessary. This determines whether the patient will be covered and gives the go-ahead to the patient and provider to proceed with the procedure. It also allows payors to control costs as they can become aware of procedures that they consider to be medically unnecessary early on.

While an essential aspect of scheduling, I know from experience that this interaction between provider and payor can slow down the scheduling process. If the authorizations are not granted in a timely manner, it can lead to backlogs, delays and ultimately lost revenue.

Often, authorizations (which include medical records, diagnosis, procedure and authorization number), are submitted to the insurance company after an appointment has been scheduled and sometimes even post the date of service, making the timely return of authorizations a matter of great importance.

THE CHALLENGES

The challenge many organizations face is the slow and unpredictable return of authorizations from insurance companies. Depending on the payor, some responses can take a number of months. This is particularly true when it comes to government payors.To make matters worse, often the representatives responsible for scheduling appointments and submitting authorizations are under huge pressure to perform a multitude of competing tasks in the healthcare contact center. According to the American Medical Association:

“medical practices will complete: 29.1 prior authorizations requests per physician per week that take 14.6 hours to process”

And we all know how much of this time in spent waiting on hold.  This can mean prior-authorization representatives have little opportunity or bandwidth to chase and follow-up with payors on authorizations submitted.  Understaffed, overworked, and dealing with huge volumes of authorizations, administrative staff find it difficult to keep track of authorizations which creates a vicious cycle of backlogs and missed revenue.

This is one of a number of areas where RelateCare can be a critical partner to healthcare organizations.

RELATECARE’S SOLUTIONS

RelateCare provide the knowledge and insight required so that you can optimize your healthcare contact center and authorization process to ensure you are submitting and following up on authorizations in an efficient and timely manner.

For a number organization across the U.S. we have added value to the revenue cycle process by working on one or all of the following:  

  • Establishment of a set of Standard Operating Procedures designed to ensure correct documentation of process workflows and management procedures.
  • Introduction of a robust Quality Assurance Program designed to identify areas of strengths and areas for opportunity across the prior-authorization team.
  • Creation and development of training materials specifically designed and customized for Prior Authorization Representatives.
  • Development of a suite value-adding reports enabling leadership to make data-driven and informed decisions.
  • Optimization of the work-queue process to increase efficiencies and remove non-value adding tasks.
  • Deployment of a best-in-class Performance Management Framework development to formally introduce new quantitative and qualitative KPIs for staff at all levels at the organization

STRATEGIC OUTSOURCING

Additionally, many hospital systems are utilizing outsourcing partners to overcomes challenges in their revenue cycles process. RelateCare has been providing strategic outsourced support to organizations who are overwhelmed with the volume of authorizations for a number of years.

This involves a highly qualified dedicated RelateCare team working around the clock from one of our two state-of-the-art contact centers to support the submission and follow-up of authorizations. This team utilize online portals, faxes, incoming and outgoing phone calls to submit and follow-up on authorizations for all specialities, clinic visits, diagnostic/imaging testing, inpatient/outpatient surgeries and primary care physician referrals.

This can eliminate large amounts of work from your organizations by transferring it into the hands of trained experts who can submit requests and documentation to payors. This can also assist in understanding why a denial occurs and work with the payor to approve your request in a timely manner. The results of these comprehensive and tested solutions include more timely and efficient authorization responses from insurance companies.

CONCLUSION

With today’s healthcare organizations focusing more on doing more with less, hospital leaders must manage their capital and human resources carefully to handle core business functions.  RelateCare offers an undeniable value proposition to healthcare systems seeking to expand their footprint and increase efficiencies. With the right consulting and outsourcing solutions partners, hospitals can focus their time, attention and dollars on what counts – the patient.

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