The Prior Authorization Workflow Framework

Last week, we went in-depth, highlighting the significant challenges with manual prior authorization processes. So, where does that leave your organization in terms of next steps? Every healthcare organization will have its own (often variable) processes and workflow nuances for handling prior authorizations based on a combination of its EMR workflows (and limitations), unique mix of payers, and broader organizational structure. However, there are existing frameworks that can be useful in identifying opportunities for analysis, optimization, and, ultimately, automation.

Step 1: Order Entry or Appointment Scheduling

The process of initiating a prior authorization begins with a provider's encounter with a patient and their request for a particular service, such as surgery, diagnostic imaging, or medications. During the visit, billing codes and orders, including relevant ICD-10 and CPT/HCPCS codes, are typically submitted as part of the Electronic Medical Record (EMR) workflow, alongside supportive clinical documentation. However, challenges may arise, such as providers not readily accessing necessary codes or insufficient documentation to finalize consultations.

Depending on the organization's configuration and EMR system, a new order or appointment request may be directed to a patient access team member's worklist or work queue to initiate the prior authorization process. This workflow can vary based on the organization's structure, with differences in responsibility for initial appointment scheduling and financial clearance initiation, such as centralized patient access teams versus ambulatory clinics or referring clinicians' offices. Addressing these challenges is essential to ensure a streamlined and efficient prior authorization process and minimize patient care delays.

Step 2: Insurance Verification and Coverage Determination

Following order entry, insurance verification and coverage determination are the next pivotal steps. These are usually managed through an x270/271 clearinghouse process, which determines the patient's eligibility for a specific insurance plan. Challenges may arise, particularly in regions where health plans delegate risk to third-party entities such as HMOs or medical groups, each with their prior authorization processes. Additionally, alongside verifying patient eligibility, there's a need to determine if the requested service is a covered benefit for the payer's product offering, which may involve searching payer websites or making phone calls for clarification. Despite some information being available on payer web portals regarding services requiring authorizations, it may not always be easily accessible or tailored to the patient's specific health plan product.

Following coverage determination, the next hurdle is determining whether a prior authorization is necessary for the requested services. This can be complex, as the information on payer web portals may not be comprehensive or specific to the patient's health plan product. Efforts by organizations like CAQH CORE aim to standardize the coverage requirement determination as a required field in the 270/271 transaction protocol, which would streamline this aspect of the process. However, challenges persist in ensuring that prior authorization requirements are accurately identified and navigated, highlighting the need for continued efforts to enhance clarity and standardization in this critical phase of the prior authorization process.

Step 3: Prior Authorization Submission

Arguably, the submission process is the most arduous and time-intensive aspect of the prior authorization journey. Its manual nature is exacerbated by the lack of standardization and opaque rules governing submission requirements. Once insurance verification and coverage determination are completed, staff face the challenge of determining the appropriate submission method, whether via fax, phone call, or logging into a payer web portal, which can vary depending on the payer or third-party manager involved.

Upon identifying the correct portal, users must manually input a plethora of required information, including patient and provider details, billing codes, and clinical documentation. This often involves navigating through various EMR workflows, with some EMR systems lacking interoperability features necessary for streamlined data retrieval. Gathering clinical documentation, particularly to justify medical necessity, is a significant hurdle, as it may not be readily available within EMR systems.

The manual data entry process not only consumes substantial time and resources but also elevates the risk of errors, leading to costly delays or denials. Despite efforts to drive automation in prior authorizations, the complexity of aligning data elements with payer systems remains a formidable challenge. Additionally, the siloed nature of many prior authorization workflows hampers real-time documentation and coordination, making it difficult to track the status of submissions and share progress efficiently across healthcare organizations.

Step 4: Prior Authorization Verification

Verifying the status of a prior authorization is a time-consuming task, typically involving logging into various payer web portals to check for updates such as approval, denial, or requests for additional information. Delays often occur due to the variable nature of when statuses are updated, leading to inefficiencies in processing authorizations. A significant challenge arises in verifying facility status for authorizations initiated by ambulatory provider practices, both employed and affiliated. Poor visibility into submitted and approved authorizations complicates the process, requiring facility teams to navigate web portals and potentially reach out to submitting practices to correct errors often through laborious communication channels like phone, fax, or email.

For payers still reliant on fax forms, the return fax document of status decisions can lead to issues such as misdirected faxes or lost documents, further delaying the process. Phone calls to obtain authorization status can also be time-consuming, with lengthy wait times to speak with an agent. Despite efforts to address prior authorization challenges, such as robotic process automation (RPA), results have been underwhelming due to challenges like multifactor authentication, managing payer changes, and inaccurate statuses. Overall, prior authorization verification remains manual, inefficient, and error-prone, highlighting the need for innovative solutions to streamline the process and improve efficiency.

Step 5: Push Data and Documentation Back into EMR

After receiving an authorization decision from a payer, healthcare providers face the manual task of inputting relevant information into the electronic health record (EHR) or practice management system (PMS) to facilitate the claim process. This involves entering details such as the authorization tracking or reference number, valid dates, approved provider and facility, service codes (CPT or HCPCs), and units of service. Typically, there's a designated field in the EHR or PMS where the authorization tracking number is manually entered, which is then included in the 837 claim submission to the payer. Additionally, approved dates, service codes, and units are documented in a notes section, while patient access teams often document payer responses for audit trail purposes, usually through screen snippets.

However, this manual data entry process is prone to errors and consumes significant staff time. Staff members must meticulously input each piece of information, increasing the risk of inaccuracies and delays. Furthermore, there are instances where payers change approval information after prior authorization, leading to claim denials due to insufficient authorization documentation in the EHR. This highlights the challenges of manual data entry and the importance of accurate and timely documentation to ensure successful claim processing and reimbursement.

An Automated Future

Ultimately, the manual nature of prior authorization processes presents significant challenges for healthcare organizations. While each institution's workflow may vary based on EMR capabilities, payer mix, and organizational structure, there are opportunities for analysis, optimization, and automation. By addressing key steps such as order entry, insurance verification, submission, verification, and data entry, organizations can streamline the prior authorization process, reduce errors, and improve efficiency. Innovative solutions are needed to overcome the time-consuming nature of manual tasks, ultimately enhancing patient care and reimbursement outcomes. Embracing automation – like Valer –  and leveraging existing frameworks will be crucial in navigating the complexities of prior authorization workflows and achieving greater operational efficiency in healthcare delivery.