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Next Gen Prior Authorization - Streamlining with Automated Decision Support
Discover how automated decision support is transforming the prior authorization process, and see how 10Pearls Health emerges as a strategic partner in healthtech, revolutionizing prior authorization services for improved efficiency and patient outcomes.
Blog contents
As technology integration within healthcare continues, medical service companies are looking to software development firms and third-party tech partners to explore ways to leverage innovative technologies. These strategic partnerships aim to enhance service offerings and create sustainable value in a dynamic and changing industry.
Prior authorization (PA) has become a particular focus of these initiatives. Healthcare service providers are increasingly aware of the challenges and resource costs associated with this process – and are searching for ways to mitigate the undeniable obstacles it presents for patients and providers.
Understanding prior authorization
High healthcare costs in the United States have led health insurance companies to adopt utilization management strategies to reduce increasing expenses. PA is one approach that insurance companies leverage to ensure the quality and cost-efficiency of prescribed patient care.
However, this process can sometimes be inefficient and create an administrative burden for physicians, negatively affecting patient care.
The value of delivering timely care
Challenges in the prior authorization (PA) process can impact both patients and physicians. For patients, obtaining timely PA for necessary treatments or medications is crucial for reducing distress and improving health conditions.
35% of physicians have staff who work exclusively on prior authorization
Physicians spend 14 hours a week completing prior authorizations
Healthcare providers work diligently to ensure patients receive the care they need promptly. Streamlining prior authorization services can enhance the patient experience and strengthen the provider-patient relationship, fostering trust and satisfaction.
From a healthcare system perspective, efficient PA approvals are essential for maintaining operational effectiveness and controlling costs. Reducing waiting periods for PA can help minimize emergency room visits, hospitalizations, and other interventions, ensuring patients receive the right care at the right time.
Variations in accuracy
Inaccurate reviews present a challenge within the prior authorization (PA) process, affecting patient care, administrative efficiency, and healthcare costs. It’s not uncommon for initial PA denials to be reversed. In 2017, 2.1 million of the initially rejected Part D Medicare PAs were eventually approved.
This highlights opportunities for enhancing the PA approval process. When initial PA denials are later reversed, it suggests a need for greater uniformity or clarity in the criteria used by different payers.
For physicians, navigating prior authorization services can take time away from directly caring for patients. The administrative workload can lead to frustration and burnout among medical professionals, impacting the quality of patient care.
Ultimately, improving the efficiency of the prior authorization system can enhance patient outcomes and strengthen the doctor-patient relationship, highlighting the importance of ongoing reform in this process.
Leveraging automation for better care
10Pearls Health partnered with a specialty prior authorization (PA) company to optimize their existing PA platform and process by minimizing manual reviews, automating key elements of the PA workflow, and developing an easy-to-use and modernized user interface. The goal was to streamline the PA process and address the healthcare payer needs around utilization management, ultimately improving accuracy in PAs, increasing speed to market by allowing the authorization of new drugs and treatments, and turning the existing process into one that was more regimented and trackable.
Streamlining changes to prior authorization guidelines
Prior to 10Pearls Health’s involvement, the PA provider’s platform was managed by a third-party vendor. When making changes to PA guidelines, the PA provider needed to compile their guideline changes into a spreadsheet and submit them to the third-party vendor for them to configure the changes into the system; this process was inefficient and would take months to compile and validate.
The enhancements implemented by 10Pearls Health empowered PA providers to update these guidelines directly. Administration specialists no longer needed to wait months for regulation changes to be implemented by IT; they could access the system and modify PA guidelines themselves using the updated platform interface.
-
New drugs on
the market -
Regulatory
standards -
Medical policies
from payers and employers
Because guideline changes could occur for different reasons, we integrated tracking within the system to monitor and record when and why the change was implemented. This provided PA providers with full visibility into the history of changes and their impact on PA guidelines.
Optimizing prior authorization decisioning
Another significant factor impacting the timeline of prior authorizations (PAs) was the decision-making process. To improve this, we increased the accuracy of the existing automated decision support system, reducing the need for re-evaluation. The updated decisioning system approves PAs based on three critical factors.
3-Dimensional clinical decision matrix
- Does the treatment/medication address the patient’s condition?
- Is the treatment the least invasive to the patient?
- Is the treatment cost-conscious?
With an enhanced automated decision matrix in place, validation time was decreased and human error was mitigated. This enhancement improved the speed and accuracy of the PA process, ensuring decisions aligned with the latest PA guidelines.
The enhanced platform alleviated the challenges that were creating bottlenecks in the prior authorization process. Treatment times improved as the new system reviewed PAs with much greater reliability, significantly decreasing the number of PAs that physicians needed to review.
-
Improved patient access to
necessary treatment -
Increased accuracy
in care prescription -
Reduced PA lifecycle from
months to weeks
-
Reduced time-to-market for
new medications -
Reduced platform ownership
costs by 5X
Conclusion
By leveraging automation, we successfully addressed the inefficiencies in the prior authorization (PA) process for this specialty prior authorization provider, resulting in enhanced accuracy, improved patient access to necessary treatments, and streamlined operations.
The integration of innovative technologies, like automated decision support systems, has transformed inefficient prior authorization services. By embracing automation, healthcare service providers can navigate the complexities of PA with greater efficiency, ultimately delivering more consistent patient outcomes and fostering a stronger sense of trust and dependability within the healthcare system.
10Pearls Health: A strategic partner in healthtech
Innovation in healthcare is not just a pivotal opportunity but a necessity. The challenges posed by the current PA process demand advanced solutions. By partnering with forward-thinking solution providers like 10Pearls Health, healthcare service providers can leverage expertise in advanced technologies to modernize legacy systems and digitize manual processes.
We develop strategic solutions that provide meaningful benefits for both users and providers, paving the way for a future focused on patient care, efficiency, and the preservation of the doctor-patient relationship. Partnering with 10Pearls Health goes beyond developing a solution to today’s challenges; it is a step forward in the evolution of healthcare delivery.
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