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Overcoming Prior Authorization Challenges With Technology

Practice Management

Overcoming Prior Authorization Challenges With Technology

The latest survey from the American Medical Association (AMA) reveals the significant challenges posed by prior authorization in healthcare. Prior authorization, a process insurers use to manage healthcare utilization and control costs, often disrupts patient care, burdens physicians with administrative tasks, and wastes healthcare resources.

 

The Consequences of Prior Authorization

 

Conducted in December 2023, the AMA survey paints a stark picture of the impact of prior authorization:

 

  • Patient Harm: Nearly one in four physicians (24%) reported that prior authorization has led to serious adverse events, including hospitalization, permanent impairment, or death. Furthermore, 93% of physicians observed a negative impact on clinical outcomes, and 94% noted delays in accessing necessary care, often causing patients to abandon their treatment due to struggles with health insurers.
  • Administrative Burdens: Physicians complete an average of 43 prior authorizations per week, consuming about 12 hours of physician and staff time. Over a quarter (27%) of these requests are often or always denied, contributing to increased burnout, with 95% of physicians indicating that prior authorization significantly increases their burnout.
  • Wasted Health Resources: An overwhelming 87% of physicians stated that prior authorization requirements lead to higher overall healthcare utilization. This includes diversion of resources to ineffective initial treatments, additional office visits, urgent or emergency care, and hospitalizations, indicating significant waste rather than cost savings.

 

These findings highlight the urgent need for comprehensive reforms in the prior authorization process. The AMA strongly advocates for state-level reforms and supports federal legislation to streamline prior authorization procedures within Medicare Advantage, aiming to prioritize patient access to care, reduce administrative burdens, and preserve resources for high-quality care.

 

In-Depth Survey Results

The latest "AMA Prior Authorization Physician Survey" underscores the persistent challenges that physicians face with prior authorizations, a strategy payors use to ensure necessary treatments. However, most physicians agree that this tactic does not benefit them or their patients.

 

The survey included 1,000 practicing physicians (400 primary care and 600 specialists), revealing that 94% experience care delays due to prior authorizations, and 78% say that prior authorizations can sometimes lead to treatment abandonment.

 

For some patients, these outcomes have severe consequences. Almost a quarter (24%) of respondents reported serious adverse events, including hospitalization (19%), life-threatening events (13%), and disability, permanent damage, or death (7%).

 

Administrative burdens are also a significant concern. Physicians complete an average of 43 prior authorizations per week, with staff dedicating about 12 hours to this task. Some staff members work exclusively on prior authorizations. Moreover, 73% of physicians reported an increase in denials over the past five years, while only 3% saw a decrease. Despite the rise in denials, less than one in five physicians always appeal adverse decisions due to pessimism about success, the urgency of patient care, and insufficient resources.

 

Even when appeals are made, the process is flawed. Only about 15% of physicians in peer-to-peer reviews believed the health plan’s peer had appropriate qualifications, although the frequency of such reviews has increased over the last five years.

 

Prior authorizations also lead to greater overall healthcare utilization, as reported by 87% of physicians. Ineffective initial treatments (69%) and additional office visits (68%) are primary contributors, with emergency department visits (42%) and hospitalizations (29%) also noted.

 

NantLink™ - A Streamlined Solution

 

In response to these challenges, NantHealth introduced NantLink, an innovative electronic health record (EHR) interoperability and point-of-care solution designed to automate provider workflows, reduce administrative burdens, and enhance the healthcare experience.

 

NantLink integrates seamlessly with Electronic Medical Record (EMR) systems, providing healthcare providers with direct access to insurance information inside of their EMR. This enables them to perform eligibility and benefits (E&B), claims and authorization interactions from the system where they conduct most of their work. This technology aims to enhance workflow efficiency, with the objective of allowing providers to make informed decisions with a more holistic understanding of their patients’ medical history and potential risks. NantLink’s goal is to simplify collaboration with health plans, making it easier for providers to work directly with them.

 

The AMA survey highlights the detrimental effects of prior authorization on patient care, physician well-being, and healthcare resources. As the medical community and legislators push for necessary reforms, technologies like NantLink offer a promising solution. Dr. Haris Naseem, CEO of NantHealth, emphasizes, "We aim to empower providers to navigate the complexities of the healthcare system more effectively. NantLink is designed to give providers the tools they need to streamline their workflows and take control of their interactions with insurance companies and pharmaceuticals." With solutions like NantLink, the future of healthcare looks brighter, focusing on connectivity, collaboration, and comprehensive patient care.

 

Source: https://nanthealth.com/

 

 

 

 

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Expanded Authorization for Non-Physician Providers

Practice Management

Expanded Authorization for Non-Physician Providers:The opportunities for non-physician providers (NPP) in radiology practices continue to expand. Recently, the American College of Radiology (ACR) revised its CT and MRI facility accreditation criteria to allow NPPs to be able to directly supervise contrast administration.
12 Tips to Grow Your Medical Practice in 2023

Practice Management

12 Tips to Grow Your Medical Practice in 2023:If you are a private practice owner, you may feel it is difficult to attract new patients. By setting a plan and sticking to it, you can set yourself up for success in 2023. Medical practice management requires the collaborative efforts of all team members.
Value-Based Healthcare and Evidence-Based Treatment Rank Highest

Practice Management

Value-Based Healthcare and Evidence-Based Treatment Rank Highest:Recently, we conducted a new survey on our LinkedIn asking respondents the question, "What do you see as the most important factor that technology solutions can solve to fuel better and more efficient patient outcomes in 2023?" 
To Benchmark or Not to Benchmark: That Is the Question

Practice Management

To Benchmark or Not to Benchmark: That Is the Question:Curiosity is both a blessing and a curse. Wanting to know how you compare to other practices can be so enticing that we are sometimes willing to accept assumptions that are not always supported by the evidence.
Demonstrating the Value of Patient Access in Challenging Times

Practice Management

Demonstrating the Value of Patient Access in Challenging Times:It's no secret: Most healthcare organizations today are facing significant financial challenges - and there isn't a single culprit to blame. Instead, it's a perfect storm of circumstances fueled by an uncertain economy, workforce shortages, ongoing COVID-19 recovery, and public health issues such as RSV and the impact of delayed care. 
The Medicare Advantage Bill Was Crafted in Response to Complaints

Practice Management

The Medicare Advantage Bill Was Crafted in Response to Complaints:U.S. Senators Maggie Hassan, D-N.H., and Dr. Roger Marshall, R-Kansas, have introduced the bipartisan Medicare & You Handbook Improvement Act, which is meant to ensure that when seniors assess their Medicare coverage options, they have the necessary information they need on health plan choices and supplemental insurance.
The Advance Beneficiary Notice or ABN

Practice Management

The Advance Beneficiary Notice or ABN:An Advance Beneficiary Notice (ABN) is one of the most abused forms at a patient visit.  When we, as a patient, seek medical care, that medical care is a covered or a non-covered service.  If it is a covered service, that means that the service is payable by our health benefit plans. 
The U.S. Government and Cooperation Credit in Relation to the False Claims Act and the Federal Anti-Kickback Statute

Practice Management

The U.S. Government and Cooperation Credit in Relation to the False Claims Act and the Federal Anti-Kickback Statute:Those familiar with the healthcare industry have no doubt learned that the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) and the U.S. Department of Justice (DOJ) have identified both the False Claims Act (FCA) and the Anti-Kickback Statute (AKS) as laws critical to thwarting fraud, waste, and abuse. Often, these two laws come together in a FCA case. 
Problems Addressed Regardless of the Place or Type of Service

Practice Management

Problems Addressed Regardless of the Place or Type of Service:I can't remember if I've recently covered this topic, so one of us (or maybe both of us) may have deja vu today. We're still getting inundated with questions about Problems Addressed regardless of the place or type of service, so whether I've already covered this topic or not, it bears addressing it again.
What Is a Patient Care Policy? (+ How to Write One)

Practice Management

What Is a Patient Care Policy? (+ How to Write One):If you've never heard of a patient care policy before, then you might ask yourself if your medical practice needs another piece of business writing. The answer is yes; it's a good rule of thumb for your practice to have such a policy.
DME Billing Coverage Limitations and Exclusions

Practice Management

DME Billing Coverage Limitations and Exclusions :Durable medical equipment (DME) billing is an essential aspect of revenue cycle management in the healthcare industry. As the industry evolves, DME has grown in importance and now serves millions of patients. However, managing the billing processes and reimbursements associated with DME can be time consuming and labor intensive.
How to Reduce Patient Collections in a Medical Office

Practice Management

How to Reduce Patient Collections in a Medical Office:Putting on the dreaded collections hat is a necessary evil that every medical office can relate to. You can run a tight ship, doing your very best to collect payments at the time of service, but because of the complexities of medical billing and emergent situations, there will always be times when collecting every patient's payment is an impossibility.
What Are SOAP Notes? (And Why They’re Important for Insurance Billing)

Practice Management

What Are SOAP Notes? (And Why They’re Important for Insurance Billing):Healthcare documentation is a critical component for your holistic practice, both in terms of delivering great care to your patients and for insurance billing purposes-not to mention the importance of having some form of documentation in the event of a legal situation.
Let's Talk about Weed (As in the Doctor)

Practice Management

Let's Talk about Weed (As in the Doctor):Early September marked my 33rd year on the administrative side of healthcare. This followed my 56th birthday in April when I officially entered the realm of "pushing 60."
DENIED! CO 22-This care may be covered by another payer, per coordination of benefits?!?

Practice Management

DENIED! CO 22-This care may be covered by another payer, per coordination of benefits?!?:Coordination of benefits can be described as when two or more insurance plans work together to determine the order of coverage liability. This coordination between plans exists to avoid duplicate payment, which could result in a provider receiving payment in excess of the services provided and the total amount billed. 
A Cautionary Tale about Personal Injury Protection, Health Insurance...and Lawsuits

Practice Management

A Cautionary Tale about Personal Injury Protection, Health Insurance...and Lawsuits:Medical providers who treat individuals for injuries sustained in motor vehicle accidents (MVAs) are frequently tasked with identifying the proper insurance carrier that is responsible for payment.
Medicare Patients and Stark Law: What You Need to Know

Practice Management

Medicare Patients and Stark Law: What You Need to Know:If your medical practice treats patients covered by Medicare, then you already know that there are countless regulations you need to closely adhere to in order to avoid any issues with the government.
Implications of the Federal Trade Commission's Report on Artificial Intelligence In the Healthcare Sector

Practice Management

Implications of the Federal Trade Commission's Report on Artificial Intelligence In the Healthcare Sector:No doubt, most people have heard of the phrase, "You are what you eat," which means that what we eat and our lifestyle choices impact our health and well-being. 
Patients Charged Expensive Out-of-Pocket Fees as Doctors Stop Bulk Billing

Practice Management

Patients Charged Expensive Out-of-Pocket Fees as Doctors Stop Bulk Billing:Perth mother Jayme Lees has been bulk billed by her General Practitioner (GP) for the past six years, but when she took her newborn son for a check-up in June, she was hit with a hefty, unexpected fee. 
Telehealth Here to Stay, But Technology Needs to Catch Up

Practice Management

Telehealth Here to Stay, But Technology Needs to Catch Up:Patient care in a post-COVID-19 world is significantly different for providers who are embracing virtual care options, such as telehealth and asynchronous texting.
Why Medical Practices Need a Mobile-Friendly Website

Practice Management

Why Medical Practices Need a Mobile-Friendly Website:People worldwide are increasingly using a range of devices to access the internet. Nowadays, it's not safe to assume that all your website visitors use a desktop or laptop computer-they’re more likely to use tablets or smartphones.
Thoughts Had...Lessons Learned ® The Selling of Marcus Welby, M.D. - Part 2

Practice Management

Thoughts Had...Lessons Learned ® The Selling of Marcus Welby, M.D. - Part 2:The basic economic business model as presented by Adam Smith in his book on capitalism, The Wealth of Nations, is shown below. Adam Smith was a Scottish social philosopher and political economist who wrote a major influential book on capitalism in the 1700s. You just never know where and from whom you are going to find your answers.
Thoughts Had...Lessons Learned ® The Selling of Marcus Welby, M.D. - Part 1

Practice Management

Thoughts Had...Lessons Learned ® The Selling of Marcus Welby, M.D. - Part 1:The first article I ever wrote for BC Advantage (BCA) Magazine was for the March/April 2017 issue. It was wishfully titled, "An Alternative to Private Practice Extinction." 
Is Now the Right Time to Start a Medical Billing Company?

Practice Management

Is Now the Right Time to Start a Medical Billing Company?:Occasionally, I receive a call in my office asking my advice regarding whether or not I think it is a good time to start a medical billing company. I never answer the question directly; rather, we have a discussion outlining the positive and negative aspects of running a billing company in today's healthcare environment.
You Play a Vital Role in Protecting the Integrity of the U.S. Healthcare System

Practice Management

You Play a Vital Role in Protecting the Integrity of the U.S. Healthcare System:The U.S. healthcare system relies heavily on third-party payers to pay the majority of medical bills on behalf of patients. Healthcare insurance fraud is a pressing problem, causing substantial and increasing costs in medical insurance programs. 
Audio-Video Telehealth, Mobile Device Management, and You

Practice Management

Audio-Video Telehealth, Mobile Device Management, and You:This article addresses how to track telehealth policies while addressing HIPAA compliance and mobile device management as the United States enters a post-pandemic era. 
Best Practices for Recruiting Front Desk Medical Staff

Practice Management

Best Practices for Recruiting Front Desk Medical Staff:As medical practices bounce back from the pandemic, many are finding it challenging to recruit and hire great employees, including front desk staff.
Prepare for Telehealth After the End of Public Health Emergency

Practice Management

Prepare for Telehealth After the End of Public Health Emergency:The state and federal Public Health Emergency (PHE) declarations related to the COVID-19 pandemic created wide latitude for providers to render services via telehealth in order to prevent the higher risk of in-person contact for patients, providers, and staff.
Outsourcing Strategy 101: Crucial Questions to Ask Healthcare Billing Companies

Practice Management

Outsourcing Strategy 101: Crucial Questions to Ask Healthcare Billing Companies:Healthcare billing companies are excellent partners to the mainstream medical industry-hospitals and independent or group clinics.
FACT SHEET: The Biden Administration Announces New Actions to Lessen the Burden of Medical Debt and Increase Consumer Protection

Practice Management

FACT SHEET: The Biden Administration Announces New Actions to Lessen the Burden of Medical Debt and Increase Consumer Protection:Vice President Kamala Harris announces reforms across four areas to ease the burden of medical debt, giving more American families the opportunity to thrive.

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