In revenue cycle management, strategic priorities are continually evolving; however, the overarching goal to improve yield remains constant. Recent surveys conducted by HFMA and FinThrive, as well as the American College of Healthcare Executives (ACHE), unveil how healthcare organizations strategically approach technology investments to address key performance indicators, especially amidst rising denials and potential cash flow slowdowns.
According to the HFMA survey results1, 70% of respondents prioritize revenue increase, 60% focus on enhancing the patient experience, and 55% aim to reduce costs. Additionally, workforce challenges topped the list of hospital CEOs’ concerns in 2023, according to the annual ACHE survey of top issues confronting hospitals2. Recognizing the interconnected nature of these goals is pivotal for maintaining financial sustainability. Healthcare organizations are homing in on crucial initiatives like reducing denials and enhancing prior authorization processes—leveraging technology, third-party solutions, and process mining to do so.
This is the first, in a series of blogs, that delve into three critical areas where technology solutions directly impact priorities: accelerating the prior authorization workflow to improve the patient experience, utilizing claim status and denial analytics to boost revenue, and prioritizing process mining to enhance workflows and reduce costs.
Accelerating the Prior Authorization Workflow
The HFMA survey of healthcare organizations show that 70% of respondents consider improving the prior authorization process a key initiative, with 41% planning to invest in an electronic solution. According to the 2022 American Medical Association (AMA) Prior Authorization (PA) physician survey, a significant 93% of healthcare providers encountered care delays due to prior authorization processes. Alarmingly, 33% of these providers reported that such delays have resulted in serious adverse events for patients. This underscores the significant impact of prior authorization on patient care, highlighting its potential to compromise patient safety and treatment outcomes.
The negative effects of prior authorization on the patient experience are crucial and avoidable. Additionally, without an efficient prior authorization workflow, the likelihood of increased denials and write-offs is substantial. The 2022 Optum Revenue Cycle Denial Index reveals that nearly half of denials are caused by front-end revenue cycle issues with authorization and pre-certification accounting for 13% of denials that could have otherwise been unavoidable4.
To shore up prior authorization workflows which improve access to care and patient satisfaction while decreasing denials, health systems need to look outside their EHR for a holistic solution that avoids common workflow pitfalls. When prioritizing prior auth, it is important for organizations exploring new solutions to understand how the solution integrates into existing EHR workflows. Moreover, the ability of the solution to handle multiple payers and service lines is a must-have for large health care organizations. Many solutions cover only diagnostics and large national payers, but not regional payers or specialties such as cardiology or surgery. Therefore, it is essential to ask potential vendors about their coverage.
“At Janus, we provide a transparent matrix to demonstrate our direct connections across payers and service lines,” notes Katie Allatt, Chief Product Officer. “This information is crucial for potential customers to determine whether our solution will meet their workflow requirements. Revenue cycle leaders should not hesitate to ask vendors about their payer and service line coverage for prior authorization. A trustworthy vendor will be upfront about where they stand.” Purchasing a partial solution may result in partial efficiencies. Therefore, it is important to ensure that the solution covers all the required payers and service lines to achieve maximum results.
To effectively tackle the prior authorization hurdle, health systems can make pragmatic strides by adopting an external solution that seamlessly integrates into existing EHR workflows, spans various payers and service lines, and provides a comprehensive end-to-end solution. This strategic move not only enhances patient access and satisfaction but also acts as a robust defense against future denials, directly addressing the critical needs highlighted in the HFMA survey. Such a practical approach enables health systems to navigate challenges efficiently and build a resilient foundation for a more streamlined and patient-focused future.
Read the rest of the blog series:
1. HFMA, While increasing revenue is a top goal for 2024, improving the patient experience is a close second – specially for large health systems, HFMA Poll
2. ACHE – American College of Healthcare Executives, ACHE Top Issues Confronting Hospitals
3. AMA, 2022 AMA Prior Authorization (PA) Survey
4. Optum 2022 Revenue Cycle Denials Index
