The Changing Nature of Prior Authorization

Professional prior authorization services have changed the nature of the prior authorization mechanism.

An insider’s view of the medical and healthcare industry will tell you prior authorization is one of the areas of concerns. Prior authorization has been an integral part of the healthcare cycle, as a safeguard mechanism for patients, to restrict them from falling traps to costly services and therapies, and also helping the providers from the risk on short payments.  However, the process itself brought in some complications. The ever-growing formalities of documentation, constantly changing regulations and policies, and the inability to cope with the same platforms have affected the prior authorizations.

A 2012 study by American Medical Association (AMA) surveyed doctors and found that one-fourth of them spend more than 40 hours a week on with prior authorizations alone. The subsequent lost time amounted to an annual value $3,430 or more. Down the years, the healthcare industry has witnessed a lot of regulatory and technological changes. Today, in 2017, a similar survey declares that 94% of Medical Practice Managers still consider prior authorization as time-consuming.

In this half-decade, a prior authorization despite being grown in importance has suffered time and again.  Right now, with the Federal decision to end ACA subsidy payments has created utter confusion and uncertainty. It is seen as an absolute blow to the health security the lower to middle-class Americans have been enjoying. Around 17.6 million people in the United States were under ObamaCare. The umbrella called ObamaCare eliminated the insurances’ policy of excluding patients with pre-existing conditions. It also forced them to include children on their parents' insurance until the age of 26. Alas! Good things never stay long. The abolition of the privilege means, Interconnected in the patient-provider-payer cycle, healthcare providers to are largely affected by the implementation of this policy change. They are in fear of increasing negative impacts on their practices. They have anticipated that the rising prices of medical services, equipment, and increased premiums charged by the insurers will directly impact their practices.

The situation has worsened with the introduction of Final Rule mandated by the CMS aiming prior authorization for some DMEs, prosthetics, orthotics, and supplies (DMEPOS), which has been designed to check the rising prices and increase transparency in the process. Perceived to be beneficial to the industry, the Final Rule brought further complexities and raised the requirements of technicalities in the prior authorization process.

However, not everything is that bad! The apparent unsettled situation has been salvaged to an extent by the presence of professional prior authorization services. The role of prior auth experts has become evident as the traditional paper-work based manual prior authorization process is on the verge of getting obsolete. As the in-house staffs take the double burden of patient care and other responsibilities, their inability to cope up risks the rise in denials and rejections. Not anymore as the expert prior authorization services armed with online prior authorization platforms have enhanced the prior mechanism t a considerable extent.  Some of the leading prior authorization companies have proved their mettle being situation handlers by recording instant reduction of 80% in their costs. Service charges as low as $5 per auth serves the economic part as it does not require to employ prior auth executives as their own. Any such employment will cost them between $15 -$17 under the current minimum wage structure. These services opened their doors with an array of standalone services like RCM and practice management.

As long as the professional prior authorization services are at the helm, providers can feel safe with prior authorizations and the whole healthcare industry gets a lifeline.

Author's Note

Author of this article has written various articles, whitepapers, blog-post on prior authorizations and its services to help madical practitioners and other healthcare industry e.g. specialty pharmacy, hospitals, genomic lab testing, radiology and DMEs etc. for hiring a cost-effective prior authorization companies in the United States.