You have invested a significant amount of resources, including finances and personnel, into your EHR system, and you want to maximize its potential. Your teams are well-versed in how to use it, and your workflows are running smoothly. You may not want to look elsewhere when you have invested so much already – it makes perfect sense to want to maximize your EHR investment.
However, there may be times when your EHR alone may not be enough to streamline your prior authorization processes and ensure that there are no gaps in your workflow. It can be tough to figure out when it’s time to look for additional solutions and what systems you need to complement your existing infrastructure and create an efficient and comprehensive workflow.
How do you know when your EHR alone will do the trick and when you need to supplement its functionality? Here are some critical factors to consider that can assist you in determining when to look outside your EHR.
Understanding the Payer Mix: A Critical Consideration
In health system areas dominated by government or managed payers, your EHR solution might fall short of accommodating your diverse payer mix. Driven by large, national payers, the EHR-centric approach may not align with the intricacies of government or managed payer requirements. The key lies in recognizing the unique demands of your payer mix and ensuring that your prior authorization solution is tailored to address it comprehensively.
Tailoring to Your Setting: Acute Care and Diagnostic Services
For those in acute care settings seeking enhanced support beyond the basic diagnostic services, investing beyond the EHR becomes a strategic move. The complexities of surgical services often require a specialized approach that goes beyond the scope of a standard EHR prior authorization solution. To handle edge cases, it is important to deploy attended automations that keep your team in control. While automation can be helpful, over-automating and removing people entirely from the workflow can worsen authorization issues. Therefore, it’s better to let your team do what they do best and automate the rest.
The Resource Dilemma: Manpower and Internal Capabilities
One of the critical challenges faced by revenue cycle leaders is the availability of internal IT resources. Setting up connections, managing data flows, and ensuring compliance can be resource intensive. With EHR platforms each payer connection is treated as a standalone, meaning your team needs to set up and manage daily issues across multiple integrations. If your team lacks the manpower to implement, maintain and update these intricate connections internally, it’s time to consider external solutions. With one centralized connection source, investing in a prior authorization solution outside your EHR system can alleviate the resource burden and allow your team to focus on strategic revenue cycle initiatives.
Navigating Global Data Sharing: Balancing Innovation and Risk
It’s important to be cautious when sharing sensitive data globally, even if a payer-driven solution seems beneficial. Balancing innovation and risk mitigation is crucial. Seeking prior authorization support via an EHR platform may require disclosing a considerable amount of data, some of which you may not want to share on a global scale with payer and plan administrators. Before proceeding, you should consult with your IT, clinical, and payer contracting teams to understand potential risks and rewards from a system level.
The decision to invest in a prior authorization solution to complement your EHR is a strategic move aimed at optimizing processes and resources, accommodating diverse payer mixes, and ensuring efficient service line coverage. Careful consideration of your setting, resource capabilities, and the delicate balance between innovation and risk will guide you in making informed decisions that propel your revenue cycle toward unparalleled success.
