Can the Prior Authorization Process for Sleep Medicine be Improved?

For all but the most routine, prior authorizations (PAs) are required for many procedures, tests, and medications throughout healthcare — and sleep medicine is no different. In-lab sleep studies, many home studies, and therapeutic medications all need PAs before the provider can treat the patient.

The time involved in processing PAs siphons valuable resources away from where it’s needed. Business staff continuously processes redundant paperwork, sit on hold while waiting turns, and faxes paperwork all in the 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.

To make matters worse, 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.

Improving the Prior Authorizations Process for Sleep Medicine

Using advanced automation, PA software that uses artificial intelligence (AI) with machine learning capabilities may be the solution with the most benefits overall.

To outline, AI-driven software can be integrated bi-directionally with any sleep medicine practice’s EHR/EMR and billing system being used for client management through cloud-based technology. As soon as the PA request is received with provider/facility detail, patient demographics, and test/diagnosis information, a PA request is submitted in near real-time to the insurance payer portal required.

Advanced automation and AI-driven software continually access clearinghouses storing thousands of insurance groups and plans electronically, each with their own unique guidelines and requirements, and can determine the PA parameters for routing the request. PA claims can be initiated in near real-time with a 98+% accuracy rate, as documented by Infinx’s long-time client, RadNet.

Let’s look at the impact automated PAs can have in sleep medicine:

• Initial Processing — From the moment patient information is entered into the EHR/EMR system; guided processes monitor the key identifiers to initiate PA approval. The system stands ready to gather the required information and submit the request in near 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.

• Continuous Follow-Up — Once the PA approval has been submitted, automated follow-up occurs 24/7 until a final resolution is obtained. If additional information is required or if 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 is a burdensome administrative effort.

  With an interactive dashboard, software available today gives a practice snapshot clarity on all active PA requests so that 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 PAs, a sleep medicine practice would have much more accurate parameters to allow a more efficient process for everyone, improving the patient’s experience and allowing the providers to focus on their care.

• A/R and Claims Management — With fewer PA problems, comes less rejected or denied claims, possibly up to 31% fewer according to the MGMA, and more revenue hitting the bottom-line.

• Analytics and Reporting — Bringing full transparency to future operations, timely analytics, and reporting to pinpoint any inefficiencies or areas needing improvement so that future sleep medicine patients benefit and have an even better experience.

Let’s Look at Insurance Verification as Well

The first step in this process is securing accurate and valid insurance and demographic information about the patient. By utilizing a transparent insurance verification and benefits eligibility automation package, your practice will be able to track and confirm precise patient coverage details in real-time while avoiding later denials due to ineligibility.

Utilizing a seamless integration or portal, front office and scheduling staff would be able to access an extensive payer clearinghouse of over 800 payers across the country to determine eligibility and benefits in real-time, including:

• patient’s eligibility and dates of coverage,
• primary or secondary insurance relationship
• co-pay and/or co-insurance due,
• annual deductible met and remaining, and
• any out-of-pocket maximums.

With the Infinx’s Insurance Verification and Benefits solution, emergent or problematic verifications would be handled by specialists in cases such as non-automated payers, etc.

And Finally, Collecting Patient Portions Due

Once the insurance information is determined, it is critical for overall practice financial health that all estimated patient portions due are collected before the time of service if possible. Today’s consumer is conditioned to pay before receiving goods or services, but it is often the practice or hospital that neglects to ask for payment until the patient arrives or even after insurance has been paid.

With automated patient pay estimates, you would have the following

• Real-time patient pay estimates
• The ability to incorporate provider fee schedules to determine accurate patient estimates based on current information
• Robust cost estimation logic that enables precise and immediate amounts due

With strong, well-defined financial policies in place, expert collections training for staff, and clear-cut automated estimates available, patient portions collected before the time of service no longer have to slowly wind their way to either payment (often several months post-visit) or collections. Additionally, giving patients automated payment options greatly increases payments – patient portals, apps, email notification, etc.

As reliance on the field of sleep medicine continues to grow, differentiating your practice from others by offering pristine business support to referring providers or self-referral patients helps in secure future potential patient growth. Your referral provider base will benefit 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 is going to 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 their Prior Authorization Software and learn more about the efficiencies gained through using an electronic prior authorization solution for your sleep medicine practice.