Streamlining PLA Prior Authorization to Save Time and Money

The process of obtaining PLA prior authorization can be lengthy, with some requests taking up to 30 days to be approved. This delay can lead to significant financial burdens for patients and providers.

By streamlining the PLA prior authorization process, healthcare organizations can reduce administrative burdens and save time. According to a study, manual processes for prior authorization can account for up to 20% of a provider's administrative costs.

Automating PLA prior authorization can help reduce the time spent on these tasks, freeing up staff to focus on more critical patient care activities.

Prior authorization, or PA, is a process by which physicians and other healthcare providers must obtain advance approval from a health plan before delivering a specific service to a patient.

It's a cost-control process used by health plans, but it's overused, costly, inefficient, opaque, and responsible for patient care delays.

Prior approval is an aspect of utilization management, specifically prospective utilization review, where an insurance payer assesses factors like medical necessity, prior treatment, clinical indications, and total therapy cost to determine if a cost-savings can occur.

PA is also known as precertification, prior notification, prior approval, prospective review, prior review, pre-cert, pre-auth, and prior-auth, and is often shortened to "auth".

Unfortunately, PA is responsible for 92% of care delays, treatment abandonment, and 853 hours per year of wasted staff time.

Automation can bring significant relief to healthcare providers and their staff, who often report that prior authorization (PA) is a time-consuming, expensive, and frustrating process.

The American Medical Association (AMA) reports that 84% of doctors surveyed found their preauthorization burden to be high or extremely high. This burden can be attributed to the complexity and limited commonality of authorization policies among payers and plans, which results in a mere 8% commonality among 1,300 procedure-specific authorization policies.

Automation can help reduce this burden by streamlining the PA process, freeing up nurses and administrative staff to focus on serving patients.

Automating PA can also lead to significant cost savings for providers. According to the AMA, the PA cost to providers can be as high as $82,000 per year, with a recent study showing that PA is on the rise.

Here are just a few ways automation can benefit healthcare providers:

Time is money, and in the healthcare industry, it's no exception. The median spending for a primary care practice to obtain pre-authorization is a staggering $47,707 per full-time physician. That's a lot of money that could be better spent on patient care.

In fact, the industry-wide cost of obtaining pre-authorization is a whopping $23 billion to $31 billion annually. To put that into perspective, that's a lot of hours spent on paperwork and phone calls that could be spent on actual patient care.

According to CAQH, health care providers could save $7.5 billion annually by switching to electronic authorizations. But it's not just about the money; it's also about freeing up time for nurses and administrative staff to focus on serving patients. By outsourcing pre-authorization, providers can recover time to see more patients.

Here's a breakdown of the estimated labor costs to doctors for obtaining pre-authorization:

These numbers are staggering, and it's clear that the current system is broken. By switching to electronic pre-authorization, providers can save time and money, and focus on what really matters: patient care.

Absent-minded errors are a common reason for denied authorizations.

Making sure all relevant fields are completed accurately can greatly speed up the PA process.

Missing or incorrect patient demographics are among the top ten reasons for denied authorizations.

Filling out fields such as F/L Name, DOB, Sex, and SSN correctly is crucial.

The CPT code for a procedure must agree with the patient's age and sex to avoid denied authorizations.

Here are the top three reasons for denied authorizations in a concise list:

Radiology and Diagnostic Testing are hit hard by PA denials, making it difficult for doctors to form a diagnosis without evidential data.

Time is of the essence in Radiology, and traditional PA methods can lead to inevitable denials, which can be avoided with electronic Prior Authorization (ePA).

A 2017 survey found that providers who used only an electronic method for PA requests spent 2.5 fewer hours on authorizations each week, but surprisingly, only 24% of respondents relied solely on ePA.

Change is slow, and although 96% of payers are committed to fully electronic automated solutions, finding and implementing an authorization system that works with existing practice management systems and EHRs can be a challenge.

A significant technology gap exists due to the inability of software makers to reconcile the incomprehensible variables of over 2000 health plans that each have their own prior authorization request form.

This gap has resulted in a staggering $23 billion dollars a year in cost burden for doctors.

The standardized form for electronic precertification, the ANSI 278 Services Authorization, has been in place since 1996 by HIPAA regulations.

However, unlike electronic claims, e-prescribing, and eligibility, States have not forced insurance payers to adhere to long-established standards.

This lack of enforcement has left doctors to bear the cost burden of an industry-wide problem of no form standardization.

In contrast, when you look at an insurance company skyscraper, it's clear that the industry has the resources to address this issue.

The disparity between the insurance industry and family doctors is striking.

Radiology denials are a significant challenge for healthcare providers.

No prior authorization (PA) means a denial is inevitable, especially in Radiology and Diagnostic Testing.

A physician needs evidential data to form a diagnosis, but payers often rely on actuaries, creating a care vs profit controversy.

Time is of the essence in Radiology, and only electronic prior authorization (ePA) can address this time-sensitive problem.

Approval can be obtained electronically in minutes or hours, making ePA a valuable solution.

This is particularly important in Radiology, where delays can have serious consequences for patient care.

The area is hit especially hard by PA denials, making ePA a crucial tool for healthcare providers.

Outsourcing PA can have numerous benefits, including reduced costs, freed up time for nurses and administrative staff to focus on patient care, and more timely care for patients as a result of faster authorization turnaround.

Reducing costs is a major advantage of outsourcing PA, as it can lead to recovered time to see more patients.

A 2017 survey found that providers who used only an electronic method for PA requests spent 2.5 fewer hours on authorizations on average each week.

However, only 24% of respondents rely solely on electronic PA.

Implementing an authorization system that fully manages the process can be a challenge, particularly when it needs to work with existing practice management systems and EHRs.

Despite this, 96% of payers are committed to fully electronic automated solutions to help solve their determination process.

CareConnections offers a web-based PA system, PAS, that simplifies referral coordination and offers a free clinical practice guideline in conjunction with their services.