One question that comes up a lot is how to fill out prior authorization forms for the various insurance payers. Until there is one standardized process that is, hopefully, mandated to be electronic, there will continue to be forms and guidelines specific to each insurance payer that take a burdensome amount of time and effort to organize, complete, and submit.

The problem is that when using a manual prior authorization process, you have to keep track of literally hundreds of forms and scenarios that change with each payer and individual state, where you see patients and often by each group and plan. There are specific processes and forms required for testing, procedures, and prescriptions — it seems endless!

The Sheer Volume of Work

Regardless of which insurance payer you are submitting your prior authorization forms to, it’s imperative to have the form completed accurately and thoroughly or risk having it returned as rejected, thereby delaying patient care. The problem is that there isn’t one standardized form that each insurance payer has agreed to accept but rather volumes of forms by a variety of delineators.

Looking at the top five healthcare insurance companies (as of February 2020), here are the companies with the most covered lives that require prior authorizations to be submitted on behalf of their covered patients.

#1 – UnitedHealth
Covered Lives: 70 Million

#2 – Anthem, Inc. (Blue Cross/Blue Shield)
Covered Lives: 39.9 Million

#3 – Aetna
Covered Lives: 22.1 Million

#4 – Cigna Health
Covered Lives: 20.4 Million

#5 – Humana
Covered Lives: 16.6 Million

When you add in Medicare and the variations of insurance carriers, it’s no wonder why the American Medical Association’s (AMA) recent survey stated that 91% of doctors reported significant delays in care for patients due to the prior authorization process.

How Would Automating Prior Authorizations Improve Workflow?

In the 2019 CAQH Index, Conducting Electronic Business Transactions, it was reported that only 13% of practices use an automated prior authorization process. The other 87% use a manual system that takes valuable time away from patients and causes delays in treatment and care.

One answer, and one that would last into the future impacting administrative costs, bottom-line results, and the patient experience, would be to initiate a cloud-based, automated Prior Authorization Software solution. By leveraging technology that uses automation, artificial intelligence (AI), predictive analysis, and machine learning capabilities to the table, prior authorizations are managed in real-time through a HIPAA compliant interface that utilizes massive insurance clearinghouses for precise and accurate processing.

From enlisting a determination engine to ascertain if a prior authorization is required, to processing and submitting the actual prior authorization electronically, to following-up and appealing outliers, the once burdensome function that takes several hours to several days (or weeks) are now more efficient and accurate, while reducing the current manual workflow. Not only does this improve the overall patient’s experience but it cuts down on hours of administrative time necessary to manage prior authorizations by hand, which positively and positively impacts the bottom line.

To Sum Up…

Insurance payers can control costs through rigid adherence to their prior authorization guidelines and that isn’t going to change anytime soon. No amount of advocacy has been able to change that fact.

However, by taking a proactive stance through automating your prior authorizations, your practice is no longer dependent on the myriad of forms, and changing guidelines since all of that is managed electronically. You and your staff are freed up to exceed your patients’ expectations while improving your financial outlook.

Contact us to learn more about our automated Prior Authorization Software solution.