{"id":11249,"date":"2023-03-01T19:49:10","date_gmt":"2023-03-01T19:49:10","guid":{"rendered":"https:\/\/risefoc.com\/?p=11249"},"modified":"2023-03-01T19:49:10","modified_gmt":"2023-03-01T19:49:10","slug":"watch-out-for-these-prior-authorization-pitfalls","status":"publish","type":"post","link":"https:\/\/risefoc.com\/watch-out-for-these-prior-authorization-pitfalls\/","title":{"rendered":"Watch out for These Prior Authorization Pitfalls"},"content":{"rendered":"<p><img fetchpriority=\"high\" decoding=\"async\" class=\"aligncenter size-large wp-image-11250\" src=\"https:\/\/risefoc.com\/wp-content\/uploads\/2023\/03\/doctor-denial-1024x683.png\" alt=\"\" width=\"800\" height=\"534\" srcset=\"https:\/\/risefoc.com\/wp-content\/uploads\/2023\/03\/doctor-denial-1024x683.png 1024w, https:\/\/risefoc.com\/wp-content\/uploads\/2023\/03\/doctor-denial-300x200.png 300w, https:\/\/risefoc.com\/wp-content\/uploads\/2023\/03\/doctor-denial-768x512.png 768w, https:\/\/risefoc.com\/wp-content\/uploads\/2023\/03\/doctor-denial-1536x1025.png 1536w, https:\/\/risefoc.com\/wp-content\/uploads\/2023\/03\/doctor-denial.png 2000w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/><\/p>\n<p><span style=\"font-weight: 400;\">Missing a prior authorization can mean costly claims denials. However, prior authorizations are more complicated than ever \u2013 learn the info you need to stay on top of the issues in 2023.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Insurance prior authorizations are a topic of contention between the provider and payer sides of the healthcare ecosystem. Healthcare payers \u2013 both government and private \u2013 use the prior authorization process to ensure that treatment choices are appropriate, legitimate, and cost-effective. Conversely, these time-consuming prior authorizations and associated claims denials are often causing delays in care and frustrations for providers and patients.\u00a0<\/span><\/p>\n<h1><span style=\"font-weight: 400;\">The Problem with Prior Authorizations<\/span><\/h1>\n<p><span style=\"font-weight: 400;\">The <\/span><a href=\"https:\/\/revcycleintelligence.com\/news\/prior-authorization-burden-continues-to-rise-physicians-report\"><span style=\"font-weight: 400;\">AMA reported<\/span><\/a><span style=\"font-weight: 400;\"> that <\/span><i><span style=\"font-weight: 400;\">940 out of 1000 providers<\/span><\/i><span style=\"font-weight: 400;\"> saw delays in care due to prior authorizations (PA), and 8 in 10 said that they have had patients abandon treatment while waiting. 86% of these physicians surveyed by the AMA also felt that the prior authorization burden has increased significantly over the past five years. Over one-third of these physicians also have staff who exclusively work on prior authorizations as their primary job function.\u00a0\u00a0<\/span><\/p>\n<p><b>Even more concerning \u2013 24% of physicians surveyed reported that the prior authorization process and associated delays have led to an adverse event for a patient.<\/b><span style=\"font-weight: 400;\"> These adverse events range from the need for more treatment, more medication, or even hospitalization.\u00a0<\/span><\/p>\n<h1><span style=\"font-weight: 400;\">The Movement for Change<\/span><\/h1>\n<p><span style=\"font-weight: 400;\">Due to these startling statistics and other industry problems with the fragmented and time-consuming prior authorization process, legislation has been pushed by the AMA, the Council for Affordable Quality Healthcare (CAQH), the American Hospital Association (AHA), and several other organizations to reform and improve prior authorization by:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Selectively applying requirements<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Lessening the volume of requirements<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Improving transparency<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Protecting the continuity of patient care<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Automating standardized processes<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">The bill, <\/span><a href=\"https:\/\/www.congress.gov\/bill\/116th-congress\/house-bill\/3107\"><span style=\"font-weight: 400;\">H.R. 3107 \u2013 Improving Seniors\u2019 Timely Access to Care Act<\/span><\/a><span style=\"font-weight: 400;\"> \u2013 was introduced in 2019 but has lain stagnant since that time.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Meanwhile, on Dec 6<\/span><span style=\"font-weight: 400;\">th<\/span><span style=\"font-weight: 400;\">, 2022 \u2013 <\/span><a href=\"https:\/\/www.cms.gov\/newsroom\/press-releases\/cms-proposes-rule-expand-access-health-information-and-improve-prior-authorization-process\"><span style=\"font-weight: 400;\">CMS proposed a ruling<\/span><\/a><span style=\"font-weight: 400;\"> to improve the Medicare and Medicaid prior authorization process for patients and providers in 2023. This proposed rule includes provisions for an expedited turnaround, more documentation, and streamlined interfaces. It also calls for a clear appeal process for authorization decisions. Providers\u2019 ability to efficiently and expeditiously meet prior authorization requirements affects every facet of their practice and revenue cycle:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Claims denials and delays reduce revenue and slow cash flow.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Frustrated patients are less satisfied with the care and may assign fault to the provider.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">More complicated processes and more procedures requiring PA mean a heavier administrative burden and cost for providers.\u00a0<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">Meanwhile, until the systematic change takes place, providers will need to deal with prior authorizations in the most efficient ways possible to minimize delays to their patients \u2013 and their cash flow. Claims denials are on the rise for multiple reasons, many of which are tied to multi-step PA procedures.\u00a0<\/span><\/p>\n<h1><span style=\"font-weight: 400;\">How Can Providers Manage these Requirements?<\/span><\/h1>\n<p><span style=\"font-weight: 400;\">For optimum workflow, the <\/span><a href=\"https:\/\/www.ama-assn.org\/practice-management\/prior-authorization\/5-tips-minimize-prior-authorization-delays\"><span style=\"font-weight: 400;\">AMA recommends<\/span><\/a><span style=\"font-weight: 400;\"> these five tips for provider practices when dealing with prior authorization burden:<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><b>Check PA requirements <\/b><b><i>before<\/i><\/b><b> providing services or sending prescriptions to the pharmacy.<\/b><span style=\"font-weight: 400;\"> This will proactively manage delays and prevent the back-and-forth cycle of calls and faxes that easily frustrate everyone involved.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><b>Establish a documentation protocol that \u201cchecks the boxes\u201d to document required data for prior authorization.<\/b><span style=\"font-weight: 400;\"> Typical practices are dealing with the same procedures and\/or medications on a frequent basis, making it easy to incorporate these into the documentation.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><b>Re-evaluate if the prior authorization submission method you use is the best.<\/b><span style=\"font-weight: 400;\"> Prior authorizations can be submitted via phone, fax, secure email, health plan portals, and standard electronic transactions. You can assess the advantages and disadvantages of each method by using the <\/span><a href=\"https:\/\/www.ama-assn.org\/practice-management\/sustainability\/prior-authorization-practice-resources\"><span style=\"font-weight: 400;\">AMA toolkit<\/span><\/a><span style=\"font-weight: 400;\"> and then select the method that best fits your workflow.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><b>Track delays and follow-ups using shared tracking software.<\/b><span style=\"font-weight: 400;\"> Following up on prior authorizations is primarily a manual process \u2013 which results in requests \u201cfalling through the cracks\u201d and getting missed at times.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><b>When a prior authorization is inappropriately denied, <\/b><b><i>always<\/i><\/b><b> submit an organized, concise, and well-articulated appeal (with supporting clinical information).<\/b><span style=\"font-weight: 400;\"> Many providers get frustrated at this point and drop the ball \u2013 which is what some payers are hoping for. By submitting electronic appeals, you can even further streamline this process.\u00a0<\/span><\/li>\n<\/ol>\n<p><span style=\"font-weight: 400;\">Looking for even more ways to optimize your revenue cycle?\u00a0 We get it! The Rise Family of Companies is ready to help with a full suite of products and services to help you prevent denials, streamline processes, and hasten cash flow. <\/span><a href=\"https:\/\/risefoc.com\/about\/#contact\"><span style=\"font-weight: 400;\">Contact us<\/span><\/a><span style=\"font-weight: 400;\"> for more information and a demo of our products.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Missing a prior authorization can mean costly claims denials. However, prior authorizations are more complicated than ever \u2013 learn the info you need to stay on top of the issues in 2023.\u00a0 Insurance prior authorizations are a topic of contention between the provider and payer sides of the healthcare ecosystem. Healthcare payers \u2013 both government [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":11250,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"content-type":"","om_disable_all_campaigns":false,"inline_featured_image":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":"","_links_to":"","_links_to_target":""},"categories":[9],"tags":[],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v21.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Watch out for These Prior Authorization Pitfalls - Rise Family of Companies | Healthrise | Qodex | Agile<\/title>\n<meta name=\"description\" content=\"Watch out for These Prior Authorization Pitfalls Rise Family of Companies | Healthrise | Qodex | Agile\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/risefoc.com\/watch-out-for-these-prior-authorization-pitfalls\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Watch out for These Prior Authorization Pitfalls - 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