Augment Your Cardiology Prior Authorization with AnalyticsPosted by William Jones on June 21st, 2024 Cardiologists are at the forefront of performing complex procedures and diagnostic tests, often entangled in the web of prior authorization (PA) requirements. Navigating the maze of insurer mandates and evolving government regulations under value-based care arrangements can be daunting. The growing patient volume and the intricate nature of cardiology procedures add layers of complexity to the PA process. However, there'sa silver lining. By harnessing the power of advanced technologies and data analytics, providers can streamline the PA process, ensuring smoother approvals and ultimately enhancing patient care.
Dive into the transformative potential of tech-driven PA solutions and discover how to turn these challenges into opportunities for excellence.
The growing Prior Authorization Problem
Prior authorization is a cost-control program implemented by the insurers to ensure defined care and reduced healthcare costs. However, the massive requirements of prior authorization make it more difficult.
It has been identified; that cardiology prior authorization problems are common in the United States. 60% of physicians stated in a survey by the American Medical Association that they usually had to wait at least one business day for their insurance to get prior authorization. Furthermore, according to 25% of the physicians, they had to wait at least three working days.
Despite a frenzy of regulatory initiatives, the problem is not expected to subside on its own, unless a firm step has been taken by the healthcare leaders.
The Potential of Analytics in Cardiology Prior Authorization
To get ahead of the cardiology prior authorization problem, health plans must implement innovative ways to optimize PA operations. Fortunately, the implementation of advanced technology and analytics can alleviate the pain of the providers and healthcare facilities.
Optical Character Recognition (OCR) for Intake: Although electronic prior authorizations are becoming more common, most are still manually filed by fax or email. OCR can help health plans convert manual submissions to electronic submissions, but we cannot expect all providers to switch to an all-electronic process overnight. A well-tuned model can save up to 72% on manual intake effort.
Predictive Models for Auto-Approval: Often, the costliest stage in the preauthorization procedure is the medical necessity review. Thankfully, it's also a fantastic application scenario for predictive models. A predictive model to support medical necessity review can be swiftly and precisely trained thanks to years' worth of historical determinations data that is kept on file internally. Up to 80% less work can be required to determine medical necessity when a model is adjusted properly.
Value-Based Care Alignment: Health plans undertake initiatives to incentivize providers for dependable, high-quality patient outcomes and even participate in financial partnerships to reduce the cost of care (e.g. limited networks). Medical necessity reviews are given priority when data from VBC and usage programs are unified, which can also help your network of high-performing providers work less.
Setting the Stage for Next
The requirement to share PA transactions via APIs was introduced by the Centers for Medicare & Medicaid Services (CMS), marking the first move toward automating PAs. Merely shifting the current manual procedures won't result in any appreciable improvements, and health plans can't afford to accept the current situation given the increasing operational burden of authorization. Furthermore, shifting to a completely AI-driven, or data-driven program overnight is not easy. You need to invest time and money to instill the best practices within the same. However, with a reliable healthcare revenue cycle management partner like Sunknowledge Services Inc., you can mitigate the challenges of cardiology prior authorization. The team of dedicated RCM experts understands what it takes to rejuvenate the revenue cycle. They have over 2000 committed staff members and an incredibly smooth authorization process, which has resulted in happy client feedback.
Are you looking for more information on how Sunknowledge can augment your cardiology prior authorization process? Connect with their experts on a non-commitment call today! Like it? Share it! More by this author |