Prior authorization ultimately has an aim to reduce healthcare costs through assurance that medication and procedure orders are clinically required. Physicians, nurses and administrators know the time-consuming burden the requirements of conducting the process place on them daily. According to a 2019 AMA Study, 15 hours of administrative time is required per week to process each physician’s average of 31 prior authorization requests. When physicians themselves are involved in processing these prior authorizations, this time equates to around $1800 per week or $97,500 per year!
Previous posts in this series have shown how automation can be used to free up cash flow and reduce uncompensated care, but can it also be applied to reduce the administrative burden of the prior authorization process? In doing so, how can patient retention be positively impacted? Intelligent Automation alone can’t eliminate all the headaches of prior authorization, but it can provide a significant benefit. In this post, we’ll dive into the benefits of automating prior authorizations!
Over the last five years, 90% of physicians have reported that the administrative burden of prior authorization has increased each successive year. This is backed in statistics that have shown on average a 14% increase in the number of prior authorizations required.
We can quantify the cost to a provider using a simple calculation. Using the statistics from the AMA study presented in the introduction to this blog, we see that an average of 15 hours of administrative time is spent on prior authorizations each week per physician. While some physicians are involved in all prior authorization work, for this example we’ll assume 50% of the 15 hours is spent by the physician, and 50% is spent by administrative employees whose cost to the business is lower. We’ll use $125 per hour for the average loaded physician cost, and $25 per hour for administrative staff. Using these numbers, prior authorization processes cost the provider $1,125 per week, or $58,500 per physician!
Robotic Process Automation (RPA) allows software robots to be created that mimic the activity of human staff performing a repetitive business process. The software robots interact with electronic systems in the same way that humans do. They can interact with desktop, thin client and web-based applications, read and send email, extract information from text or handwritten documents, and much more. This means that existing electronic systems do not have to change to automate processes with RPA, and that complex programmatic systems integration can oftentimes be avoided OR orchestrated more easily through RPA itself.
There are multiple ways that RPA can be applied to streamline the Prior Authorization process. One way is in determining the authorization requirement for a particular order by quickly ingesting orders and referrals in as real-time as possible and running checks against the individual plan and member benefits. By using automation, the most recent payer rules can always be used, ensuring that changes in these rules don’t result in an incorrect determination of authorization requirements. Though some EMRs now have capability to flag orders requiring prior authorization, this capability is only as accurate and up to date as the payer information updated in the system. RPA can be used in this scenario to keep this information up to date in the EMR with minimal need for human intervention, reducing the chance for error or missed updates.
Once the determination of authorization requirement is made, automation can be used to handle a significant percentage of submissions without the need for physician or admin staff involvement. RPA can submit for authorization multiple ways, such as through a payer’s website, or by using EDI 278 requests and responses depending on procedure and payer specifics. Automation also ensures that any additional documentation required to prove medical necessity for specific procedures or payers is submitted each time. In all cases, RPA can then be used to continually check whether the payer has made an authorization determination, and feed that result back to update the order.
By streamlining the determination of authorization requirements, as well as the submission process, the amount of time a patient waits to schedule follow-up is significantly shortened, all while overhead placed on clinical and administrative staff is significantly reduced. Besides the obvious upsides to scheduling patient follow-up more quickly, there are additional gains in process that are allowed by the automation. For example, because of the reduced authorization times, scheduling of follow-up appointments can wait to occur until authorization feedback is received. Doing so reduces the chance of having to contact a patient to slip an appointment back or change a care plan altogether. This is a significant benefit that automating the prior authorization process has to patient experience. It means that there are fewer chances that scheduled appointments have to be postponed, which helps gain patient trust and increase retention. In fact, scheduling the future appointment when the authorization is received is also something that can be automated to streamline process, and this topic will be covered in a later blog post in this series.
As can be seen in just a few of the examples above outlining how RPA can be applied to the prior authorization process, there are significant financial, procedural, and patient experience benefits to be had. Additionally, using the average of 15 hours per week spent on each physician’s prior authorizations, automation has the benefit of freeing up 780 hours of time annually per physician! If even half of that time is reclaimed from the automation, the additional revenue that can be generated by the freed physician time, in conjunction with the savings in administrative time, more than covers the investment to implement the automation. It’s one more reason that pureIntegration stresses with customers that automation initiatives can often be self-funding, with the savings and additional realized revenue more than offsetting the cost of implementation.
pureIntegration has been partnering with our customers to automate their most challenging business and technical processes for over 15 years. We offer flexible engagement models and a factory approach to automation development—from building and maintaining automation long term as a managed service, or by building internal development expertise and an operations model (Center of Excellence) to drive automation initiatives, our team can get you off the ground quickly. Engage with us today to find out how to put 80,000 hours of automation experience to work for you!