How Rev Cycle Leaders Leverage Automated Prior Auth Solutions

Payer updates and policy changes delay reimbursement; Leaders say automated solutions can help fight back.

The tug-of-war between providers and payers over prior authorizations is a consistent and costly issue.

While Illinois-based Carle Health System does a good job of managing this issue in the front-end, it takes 36.5 days to appeal a denied prior authorization request.

“Last year, we were somewhere around 46 days, so we’ve dedicated additional resources to that overall process,” says Aron Klein, vice president of finance operations and supply chain. “We’ve seen considerable growth in all denials, not just prior authorization denials.”

The system has seen a 22% increase in denials year-over year, the majority of which, Klein says, citing additional documentation requests or information needed, creating a mountain of administrative work.

Payer policies and requirements for prior authorizations are prone to changes, so being able to have forms populated with information from the system’s EHR and sent to the payer takes the administrative burden off staff.

According to Jessica Godbey, vice president of patient access services, the system’s prior authorization solutions save specialists 10 minutes per request and connects with 80% of the payer market.

Carle Health also uses technology to seamlessly map CPT codes for high-dollar surgical procedures to ensure more accurate authorization submissions.

“Our staff are so invaluable to us. It really allows them to focus on those more complex detailed accounts,” Godbey said.

However, she adds that solutions will not be able to replace the human connection with patients. She acknowledges that solving this challenge will take a mix of innovative technology and individual expertise.

“We are committed to offering the world-class experience possible for our patients both at the bedside and throughout their billing facilitation,” Godbey said. “We are bringing technologies and a patient-centered approach to alleviating the complexities of managing the care authorization process.”

While payers “express openness” to the system’s concerns, Klein says, they don’t move as quickly as the system would prefer towards a resolution.

“Payers rely on technology solutions just like we do to manage processes on their side,” he says. “Which ultimately if something [happens] on their side, it takes time to resolve, which ultimately delays processing or receipt of payment on our side.”

The revenue cycle partners meet every month to review prior authorizations and denials, monitoring progress to see if there’s a decline in denials and making note of any trends. Health system leadership is kept up to date on these findings, Klein says, so they and the operations teams can assist in their resolution.

Some denial trends they’ve seen have been interoperative CPT code changes, changes to CMS’s two midnight rule, and frequent change to the payers own rules and regulations.

Going forward, Carle Health is looking to continue expanding staff bandwidth through automation to reduce costs and administrative burden further and leveraging [staff] talents respond to more complicated denials.