Technology hurdles, particularly lack of standardization and interoperability, often hinder the prior authorization process. Robust communication strategies can address those problems.
Prior authorization (PA) is a persistent source of frustration and administrative burden for health systems. While technology can streamline the process, challenges around interoperability and lack of standardization across payers often limit effectiveness.
Savanah Arceneaux, director of pre-service & financial clearance at Ochsner Health, Christine Migliaro, vice president of front-end revenue cycle operations at Northwell Health, and Samantha Wyld, partner and senior director at Optum Advisory, shared their thoughts on the PA process during last month’s HealthLeaders Revenue Cycle NOW Online Summit, sponsored by Optum.
Interoperability woes hinder PA authorization automation
The lack of standardization in the PA process was a popular topic.
Each payer has its own processes for PA, and some still rely on fax machines and phone calls. While technology can make the process easier, it can still require multiple logins for the various digital payer portals.
Those payer portals lose their utility if the payer technology can’t communicate with the provider technology.
“Even if we find the right solution out there,” Migliaro observed, “can it talk to all the different systems that we are utilizing and be able to leverage that data?”
Challenges associated with too many technologies are more apparent when PA is done at the practice level, according to Migliaro.
Centralized teams dedicated to PA can effectively manage multiple technologies and processes. However, this becomes more difficult for a practice-level administrative assistant who is primarily responsible for answering phones and greeting patients.
Interoperability issues arise even for technologies with significant market share. Ochsner, like so many other health systems, uses the Epic EHR. While Epic offers a payer platform, too few payers are using it to significantly impact efficiency, according to Arceneaux.
Ochsner has automated some components of the PA process, like claims status processing, giving staff time to work on higher value activities, according to Arceneaux. However, a lack of standardization across payers has limited benefits to technology in the prior authorization space.
“We’re not able to connect this way to all of the payers and see that big volume that we would like,” Arceneaux said.
Bridging communication gaps in the PA process
Currently, PA technology platforms are more of a partial fix than a panacea. Where it is difficult for those technologies to communicate with each other, RCM staff need to step in. Maintaining open lines of communication with both payers and providers is one key to minimizing frustration, according to both Arceneaux and Migliaro.
Within a system like Ochsner, where pre-service and financial clearance teams have been centralized, there is significant opportunity to standardize communication among all PA players.
Staff dedicated to PA work within specific service lines, allowing them to develop deep knowledge of PA requirements. A separate team dedicated to denials identifies areas for improvement, while another team tracks changes to PA requirements and payer policies. Changes are communicated to the appropriate providers through the appropriate channels, all of which helps to inform continuous process improvement.
While joint operating committees offer opportunities for routine communication between health systems and payers, “dedicated payer contacts are really crucial to your success,” Arceneaux said.
At Northwell, which does not have a dedicated PA team, there is less of a top-down approach to communication.
“One of the biggest things that we have to do is make sure that we learn and share from all the individual practice operations,” Migliaro said.
Migliaro also stressed the importance of strong relationships with payers. Maintaining open lines of communication with payers can allow revenue cycle leaders to learn why denial rates are high or why turnaround times are long.
Despite the negative mood surrounding PA, revenue cycle leaders should recognize the silver linings, Migliaro said.
“We always talk about the stuff that isn’t working, but I also think it’s really important to give people feedback on stuff that does work and to celebrate the wins.”
Watch a recording of the webinar below or visit the HealthLeaders YouTube channel for more content.
Luke Gale is the revenue cycle editor for HealthLeaders.
KEY TAKEAWAYS
Interoperability issues and lack of standardization limit efforts to streamline prior authorization using technology.
Maintaining open lines of communication with payers and establishing dedicated payer contacts can relieve some of the frustration in the prior authorization process.