By John E. Duldner
Prior authorization, also known as precertification or prior approval, is a complex process involving multiple stakeholders. Often perceived as a tug-of-war between providers and payers, it is important to remember that the patient is in the middle with a limited understanding of the process. Providers view precertification as a nuisance, but payers’ perspectives are focused more on cost-control, evidence-based medicine, and abiding with plan coverage limitations. The Utilization Review Accreditation Commission formally outlines precertification as the evaluation of the medical necessity, appropriateness, and efficient use of health care services, procedures, and facilities
under the provisions of the patient’s health benefits plan.
Historically Slow Evolution
Since its inception, precertification has evolved only slightly from its rudimentary process. Technology has improved information organization, but overall it has not impacted stakeholders significantly, at least not until Quickprecert.com has
become available.
A Step-by-Step Solution
Everyone agrees that there should be a better system for prior authorization, but only recently has such a solution become available. The ideal system would consist of at least four components. The first, and most important component, is a precertification process targeted to payers’ specific medical policies. Second, a streamlining customized data entry that automates the process. Third, a reduced burden of work and improve revenue. Finally, unparalleled customer support. These features and more are available in one secure, HIPAA-compliant cloud service.
Targeted Precertification Leads to Success
Precertification essentially amounts to sending clinical information to the payer, requiring them to sort through volumes of (unnecessary) information to determine if the medical information meets their medical coverage policies. Research has shown that among 1300 procedure-specific authorization policies, there is only an 8% commonality among 23 major health plans.1 Quickprecert. com levels the playing field. It uses predefined algorithms, frontloads only the necessary clinical information specific to a payer, couples ease of data entry, organizes required supplemental clinical data, and matches the payer workflow. Using this approach, approvals are virtually guaranteed at the time of precertification submission. If the procedure request and the clinical information do not match the payer policy, you will know before submitting any information.
Streamlined Data Entry Creates Efficiency
Prior authorization processes impose substantial burdens and costs on providers. Automating as much data entry as possible will improve efficiency and decrease burdens on time and staff. The introduction of EHRs was shown to reduce precertification processing by just over 20%. However, an optimized solution can reduce precertification processes by an additional 15-20%. Furthermore, when coupled with targeted medical policy algorithms, an AI-directed solution can result in immediate approval of the procedural request. On the horizon looms additional precertification requirements, including the possibility of Medicare patients requiring prior authorization before scheduling procedures.
Reduced Effort and Improved Revenue
Industry estimates suggest that prior authorization events cost $15-$35 per occurrence. Costs can be reduced when utilizing electronic processing, but a technology-enhanced system such as Quickprecert.com can further reduce costs. The resultant gains in time can be directed at additional prior authorization requests or other vital office functions, including care coordination and patient engagement. Revenue is also strongly and positively impacted in several ways. A provider’s time and resources are optimized. Claim denials and rejected payments (after a procedure has been completed) are reduced by greater than 90 percent. Patient satisfaction with the provider and office staff is also strengthened due to rapid turnaround times from office visits to procedural approval. Quality assurance analyses related to denial management by Quickprecert.com’s clinical experts further mitigate revenue losses.
Human Customer Support is a Rarity
In today’s world of technology, it’s nearly impossible to get immediate customer support. Therefore, the ideal precertification solution has to marry automation with a human presence. Quickprecert.com’s solution provides clinical expertise in medicine, knowledge of precertification processes, responsiveness to changes in the preauthorization ecosystem, incorporation of evolving technology needs, ensures unparalleled teamwork between the provider’s office and the Quickprecert.com platform, and provides a human voice on the other end of the phone when needed.
With Quickprecert.com, the precertification process can be transformed from a necessary evil into a streamlined tool to improve patient care, allow staff to perform higher-value tasks, and increase revenue.
References
1. Dyke D. Fixing Healthcare's Broken Pre-Authorization Screening and Verification Model. HIT Consultant. Jun 27, 2016. http://hitconsultant. net/2016/06/27/revenue-cycle-pre-authorization-process/
