Beginning in early 2018, healthcare stakeholders have taken a more proactive stance in pressuring the Centers for Medicare and Medicaid (CMS) and commercial insurance payers to overhaul the prior authorization (PA) process, and the efforts seem to have picked up steam in light of the COVID-19 public health emergency.  The American College of Cardiologists (ACC) joined the American Medical Association (AMA) and 16 other groups to participate in a joint task force with the sole purpose of developing reform principles to guide a streamlined PA process and reduce friction.

While the original intention set by utilization review and PAs was a good one, the mechanics of administering them has created a cumbersome and unnecessarily awkward process with frequent denials and patient care issues.  A recent report from the AMA notes that almost 90% of physicians report that patient care is negatively affected and often results in delays in care up to and including care abandonment.

Losses Add Up with a Manual Prior Authorization Process

According to the 2019 CAQH Index on Conducting Electronic Business Transactions, as much as 87% of medical practices use a manual system to manage PAs at the cost of $14.24 per PA.  Add to that the unworked claims denials experienced from missing or rejected PAs, and the costs are astronomical.

Now compare that to the savings and efficiencies through the use of an automated system, and PAs become much more palatable and manageable as a means to gauge quality and appropriateness of care.  On a system-wide basis, this would achieve the initially intended consequences and improve the patient experience as well as the practice’s bottom line.

A Targeted Approach

By utilizing a fully automated system, the cost per PA would average $1.93 each, bringing a savings of $12.31 per occurrence.  With a PA solution that leverages artificial intelligence (AI), predictive analysis, and machine learning, the entire process could be managed in real-time for treatment, surgical procedures, advanced testing, medications, rehabilitation, etc., including:

  • Determining necessity based on patient’s referring diagnosis and insurance requirements and guidelines,
  • Collecting necessary information on patient demographics, verifying insurance benefits, and confirming allowable care,
  • Submitting completed PA to the appropriate insurance payer for review,
  • Following up by monitoring payer portals 24/7 and retrieving case status updates,
  • Generating and resubmitting appeals if necessary,
  • Providing full transparency into your PA workflow using analytics and status reporting to track every claim,
  • Supporting emergent or complex PAs through a team of highly-training, integrated prior authorization specialists available to complete and finalize outlier situations.

Does This Type of AI-Driven System Meet or Exceed Compliance Standards?

With an AI-driven PA software, all information can be integrated seamlessly from the EHR/EMR system by utilizing an HL7 or API-based bi-directional integration. It is available in real-time on a comprehensive dashboard that allows instantaneous status checks.  This exceeds all standards expected, including those set by HIPAA.

Moving into the future, automation and AI-driven technology will bring improvements to not only clinical care but also patient access and revenue cycle management, further improving operational efficiency.  Patients are already demanding low touch, high technology solutions that bring easy access and convenience.  Even now, patients are far less willing to tolerate the inefficiencies brought with manual processes; they want and demand expert resolution.

Contact us to learn more about prior authorization solutions for your cardiology practice using automation and AI-driven technology for cardiology.