Navigating Prior Authorizations: A Collaborative, Programmatic Approach is Essential

Navigating the prior authorization (PA) process has become increasingly complex, particularly for advanced molecular and genetic diagnostic testing, specialty medical devices, and remote patient monitoring services.

When evaluating options to streamline the PA process, providers often seek point solutions that address obtaining and submitting prior authorizations efficiently. This approach can be an effective first step for routine testing. However, providers managing PA requests for more complex procedures, such as genetic testing, often find the point solution not impactful enough and should consider a more programmatic approach, providing integration and visibility into the entire revenue cycle management (RCM) process.

The Programmatic Approach to Prior Authorization relies on strategic and cross-departmental collaboration across the following teams:

• RCM – Visibility, Measurement, Analytics 
• Market Access – Payor Engagement and Advocacy 
• Commercial (i.e., Sales and Client Service) –  Educating and Engaging Clients 
• Finance –  Profitability Analysis and Strategic Decisions 

RCM

The RCM team plays a crucial role in various aspects of a successful PA process. Initially, the RCM team facilitates the PA process by implementing intelligent workflow automation, streamlining the entire process, and reducing the need for manual intervention, consequently expediting reimbursement timelines. Moreover, the team possesses valuable data that grants the broader team insights into the specific PA requirements of different payor plans and services. Additionally, the RCM team monitors payor behavior changes, which can impact the success of PA requests.

Read the XiFin blog, 4 Steps to Optimize the Prior Authorization Process, for more information on how the RCM team can help streamline the PA process.

By offering visibility, measurement, and analytics into payor-specific requirements and assessing PA success outcomes based on payor, service, and referring client, the RCM team establishes an important feedback loop. This feedback loop enables targeted efforts by the Financial, Commercial, and Market Access teams to optimize future PA endeavors.

Market Access

The market access role in prior authorization involves strategic planning, payor engagement, evidence generation, performance monitoring, and advocacy to ensure patients have timely access to the company’s products and services through insurance coverage.

The market access team can also help negotiate away prior authorization requirements. By leveraging data, healthcare providers can demonstrate that they are consistently submitting only prior authorization requests that meet medical necessity policy for the given test or procedure and include all the correct forms and documentation. Demonstrating a high level of PA approvals over 12 months or more gives the Market Access team the evidence to strategically negotiate with payors to remove prior authorization requirements for specific tests, streamlining the process for all parties involved.

As the healthcare landscape evolves, achieving Gold Card status—a designation exempting physicians from PA requirements—is increasingly important. Collaboration and programmatic approaches are key to meeting Gold Card criteria and ensuring seamless patient care.

Commercial

Collaboration extends further to include the Commercial team. Educating clients, including ordering physicians’ staff, on PA requirements and understanding their existing processes are vital to this collaboration. By working closely with providers, the sales team can facilitate smoother PA submissions, ensuring all necessary documentation is provided upfront and expediting reimbursement.

We also found that when a sales team sends welcome letters to new clients outlining everything that needs to be submitted with a test specimen, for example, the success of prior authorization requests improves significantly. The XiFin team has also found that driving the adoption of portals and other electronic methods of collecting and sharing documentation supporting medical necessity increases the effectiveness of the PA process.

Financial

The Finance team also plays a crucial role in PA collaboration. The team aids in strategic planning by analyzing the profitability at both the client and test or procedure levels and identifying opportunities for improvement. It understands the Cost of Goods Sold (COGS) associated with tests and procedures. This COGS can be substantial, particularly for complex tests, and each unreimbursed test or procedure affects the provider’s profitability.

A multi-channel, collaborative approach to prior authorization management is essential for navigating the complexities of today’s payor landscape. Healthcare providers can streamline processes, improve reimbursement rates, and enhance patient outcomes by leveraging data, expertise, and strategic negotiations. Embracing a programmatic approach ensures that all stakeholders work together seamlessly towards a common goal: providing timely, high-quality care to those who need it most.

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