Can the Pain Medicine Prior Authorizations Process Be Improved?

For all but the most routine, prior authorizations are required for many procedures, modalities, and medications throughout healthcare — and pain medicine is no different. Whether because of misunderstanding or cautious administration, insurance payers seem to want prior authorizations on numerous items before the pain medicine providers can begin to treat the patient.

The time involved in processing prior authorizations siphons valuable resources away from where it’s needed while business staff process redundant paperwork, sit on hold while waiting turns, and fax or re-faxing paperwork all in hopes of obtaining a quick answer. With over 87% of healthcare providers using a manual system, it’s no wonder why the entire process feels punitive and overly burdensome.

According to the Medical Group Management Association (MGMA) 90% of healthcare leaders report that payer prior authorization requirements are increasing with no end in sight to make matters worse.

Improving the Prior Authorizations Process for Pain Medicine

Using a Prior Authorization Software that uses advanced automation and artificial intelligence (AI), leveraged by experienced specialists, is the most beneficial solution.

To outline, cloud-based, AI-driven software can be integrated bi-directionally with the pain medicine practice’s EHR/EMR and the billing system being used for client management. As soon as the patient’s order is input into the EMR/EHR system, tests or medications requiring prior authorizations would be electronically identified. In addition, provider/facility details, patient demographics, and test/diagnosis information would be collected, and an approval request submitted in real-time to the required insurance payer portal.

AI-driven software with machine learning capabilities would access continually updated insurance information clearinghouses storing thousands of insurance groups and plans, each with their unique guidelines and requirements, and electronically determine the prior authorization parameters for routing the request. Prior authorization approvals that once took several days or weeks can now be accomplished in seconds with a 98+% accuracy rate, as documented by Infinx’s long-time client, RadNet.

Let’s look at the impact automated prior authorizations can have in pain medicine:

• Initial Processing — From the moment patient information is entered into the EHR/EMR system; guided processes monitor the key identifiers to initiate the prior authorization with the payer. Matching ordered tests or medications and constantly updating insurance prior authorization requirements, the system stands ready to gather the required information and submit the request in real-time.

  Business or clinical staff no longer have to manually process forms, wait on hold, or fax repeatedly and can refocus their time on higher-level functions.

• Continual Follow-Up — Once the prior authorization approval has been submitted, electronic follow up occurs 24/7 until a final resolution is obtained. If additional information is required or an appeal is necessary, the practice is notified immediately so that a response can be crafted and submitted as soon as possible.

• Dashboard Notifications — Waiting for insurance payer responses has historically been a time-consuming affair that took hours of follow-up and burdensome administrative effort.

  With an interactive dashboard, today’s AI-driven software gives the practice a snapshot on all active prior authorization case statuses, so patient and clinician questions can be answered immediately, and follow-up can occur as necessary.

• Scheduling — Alleviating the frustrations of having to schedule and reschedule patients based on prior authorizations, a pain medicine practice would have much more accurate parameters to allow a more efficient process for everyone by improving the patient’s experience and enabling providers to focus on their care.

• A/R and Claims Management — With less prior authorization problems comes less rejected or denied claims, possibly up to 31% fewer according to the MGMA, and more revenue is hitting the bottom line. And as a bonus, AI-driven software also available can handle denied claims with a >95% quality standard according to Infinx.

• Analytics and Reporting — Bringing full transparency to future operations, timely analytics, and reporting pinpoint any breakdown inefficiencies or areas needing improvement so that patients receive an overall better experience.

As reliance on the field of pain medicine continues to grow, differentiating your practice from others by offering pristine business support to referring providers or self-referral patients helps in securing future potential patient growth. Your referring provider base will see the benefit to their patients with more timely care initiation and less cumbersome reimbursement.

While healthcare associations and government entities continue to discuss streamlining prior authorizations, it seems clear that the process itself will remain in place as a way for insurance payers to control care. Meeting the challenge seems a more prudent and proactive response instead of waiting for change to occur.

Contact Infinx to schedule a demo of our Prior Authorization Software and learn more about the efficiencies gained through automated prior authorizations and experienced specialists.