In Part 1 we pointed out the widening gap between provider and payer adoption of prior authorization automation solutions and its impact on provider finances. Here we respond to three more questions you may have regarding prior authorization automation.
How do I evaluate if a prior authorization vendor can deliver what we need?
The complexity of implementing and maintaining prior authorization solutions has led to some fairly public vendor failures. The land-grab for a largely unautomated space led to vendors underestimating the infrastructure investment and expertise required to build and maintain solutions at scale. If you or a peer organization have been affected by years-long implementations, unreliable automations, slow issue resolution, or disappointing coverage, it’s understandable you’d be wary of vendor promises.
No vendor partnership is without risk, but these questions can direct you to the right vendor for your organization:
- Is there evidence they’ve had success with other clients, like references or case studies?
- Is their pricing structured to facilitate ROI?
- What metrics do they focus on improving?
- Do they have a standardized, pre-implementation data collection process to minimize unknowns?
- Are they able to demonstrate coverage of your key payers with expertise in the ideal integration pathway for each?
- Do they structure their implementation plan to minimize go-live risk and allow for operational feedback and partnership?
By leaning into ensuring workflow expertise as well as technical acumen, you better evaluate if your potential vendor is merely a mercenary building bots or an experienced partner focused on helping solve your organization’s challenges.
Read more: Three Things to Ask Your Prior Authorization Vendor Before Signing on the Dotted Line
What can my organization do to ensure success with a vendor?
You’ve established that your preferred vendor has the expertise to build and maintain the automations you need, but they’ll still need your participation. Because prior authorization automation is so payer specific, building and testing is very individualized to the organization. You can facilitate a seamless implementation by preparing payer portal credentials, volume data, and test data in advance.
Identify the KPIs you’ll measure to evaluate success, and if they’re new to your team, establish the people and processes needed to start and continue measuring. Make benchmark measurements now so you have a clear before-and-after picture of automation’s impact on efficiency, denials, write-offs, and AR days.
Can automating prior authorizations really help me avoid denials?
Yes, but your typical denial reasons and payer mix will dictate how much. Authorization-based denials are common (averaging 13% of all denials1) but can have a range of underlying causes. Automation will increase your speed and volume of prior authorizations and can reduce manual errors, all contributing to reduced denials. But it may not account for other factors outside the automation’s functionality, like improper coding, insufficient clinical documentation, or even payer error. Automation should be part of any robust denial management strategy, but it’s only a piece of the puzzle.
That said, as many as 60% of authorization-based denials are due to missing or invalid authorization1. Your vendor should provide documentation of authorization determinations, submissions, and results. This “paper trail” may better equip you to appeal authorization-related denials downstream.
Get started today
Regulation is catching up to the increasing burden prior authorizations place on providers, but it may be years before we see meaningful change across the industry. If you’re ready to boost your efficiency and level the playing field with payers right now, learn more about Janus Health Prior Authorization.
