Timely Prior Authorizations Enhance Patient Experience and Improve Collections

A Case Study from Atom Healthcare

Prior Authorization

Improve speed to care with timely pre-authorization

Improving healthcare quality

Healthcare businesses are still catching up with the “experience” economy and need to invest in connected social, digital, and contact center infrastructure to create seamless patient experiences. Improving patient experience is now the #1 priority for healthcare CXOs as the quality of care takes the center stage. Increasingly, incentives, practice recognition, board certifications, and compensations are being awarded based on the quality of care and population health analytics. As predictive and preventive care becomes an integral element of strategies to reduce the cost of care, there is mounting pressure on service providers to craft such experiences and meet growing expectations of the patients and families in the experience economy.

Patient experience goes beyond patient satisfaction. It includes the quality of care, patient satisfaction, and their experience with their healthcare provider starting from the scheduling of the appointment to post-treatment care. To effectively focus on and deliver patient experiences, doctors, nurses, and other clinical practitioners need to be freed from the drudgery of paperwork and routine activities. Technology and third-party service-providers of revenue cycle services and medical records can be great enablers.

Background

Atom Healthcare’s client, a leading cardiology clinic with over 100 physicians, was facing significant brand erosion due to time-consuming and challenging prior authorization process leading to delays in treatment/ appointments and below par patient experience

Cardiology involves some of the most critical and life-saving treatments and procedures; delays could prove costly to the patient’s life and overall health. Hence, it is crucial that no delays in appointment scheduling.

Importance of Prior Authorization processes.

Between patient scheduling and the actual appointment comes the process of pre-authorization, where the healthcare provider obtains approval from the Payer for the procedure or treatment and verifies the patient’s insurance and eligibility. The process becomes crucial as it impacts the following:

  • If the prior authorization process is not effectively completed for treatments that require prior authorization, the payer may deny the claims leading to time-consuming appeals and, potential, loss of revenue.

  • If the patient is not eligible or if the procedure/ treatment is not approved by the insurance provider, the patient must be informed about the same. In such a case, they must pay up themselves. Upfront determination of self-pay liabilities is critical to improving self-pay collections and provides the ability to offer patient payment plans.

  • Further, it must be noted that prior authorization is one of the most non-standard processes and has a lot of payer-specific nuances, requiring business process service providers to have a very accurate understanding of both the procedures requiring prior authorization and payer-specific documentation requirements.

  • Also, prior authorization helps reduce the gaps and delays in the collection process.

Challenges

The cardiology practice was finding to be a time-consuming and challenging process on account of the following challenges

  • Lack of knowledgeable resources on prior authorization affecting timely authorizations

  • Delays in obtaining prior authorizations leading to poor patient experiences

  • Revenue leakage due to reduced self-pay collections and claim denials

Solutions

Atom Healthcare crafted a two-month plan to reduce prior authorization delays, reduce claim denials, improve self-pay collections, and improve overall cashflow cycle. The plan included the following elements:

  • Online Prior Authorization requests. Online registration was done with different payer portals to initiate prior authorization requests online.

  • Agility through offshoring. By setting up on an offshore contact center team, we were able to reduce costs, while infusing the necessary scale and agility into the prior-authorization process.

  • Streamlining requests. With an accurate understanding of payer specific prior authorization requests, we created structured business rules for each procedure requiring prior authorization and created a ready-reference repository to enable our team process prior authorization requests quickly.

  • Improving self-pay collections. Our team also coordinated with the front office staff to obtain requisite medical necessity documentation to support prior authorization requests, and once the authorization was obtained provided them an understanding of the self-pay requirements.

Results

With increased scale and standardized processes, we infused much-needed agility and responsiveness to enhance the patient experience and enable the cardiology practice to focus on what the do best, provide exceptional patient care. Our team enabled the practice to:

  • Improve the patient access experience. With coordinated scheduling, patient access, and self-pay collection processes, not only did the care delivery process become more effective but also led to the improved patient experience.

  • Improve self-pay collections by 6%. With an effective determination of patient liability, we were able to educate the front office team on patient responsibility for payments and work

  • Improve production by 20%. With structured processes, we were able to improve the overall production by as much as 20% and obtain authorizations more effectively. We also established service level measures for quality and turnaround of prior-authorization requests.

  • Reduce costs through offshoring by 30%. Through Atom Healthcare’s global delivery model, we were able to reduce the cost-to-process by as much as 30%.

Overall, the client was elated that they were able to serve their patients without having to worry about delays and cash collection.