“That’s going to need a prior authorization” are words no healthcare provider, diagnostic provider, or patient wants to hear. Today, the process of obtaining prior authorizations is complex, disorganized, and highly manual. Patients often have no visibility into the process which leaves them frustrated, and in certain instances, they abandon treatment altogether.1 Unlike other pre-service activities, such as eligibility and benefits inquiries, prior authorizations require a high level of coordination between physicians, diagnostic providers, and payors.
The current prior authorization process often involves fax, phone calls, and multiple portals which is estimated to take 20 hours of staff time per week per physician.2 Physician practices are often so overwhelmed by their own internal prior authorizations that they often lack resources to complete authorizations for ancillary services such as lab tests, imaging studies, and remote patient monitoring.
This leaves the prior authorization responsibility on service providers, but diagnostic providers in particular face a unique challenge: the date of service for a lab test is often defined by the date of specimen collection. Payors may or may not have a “retro window” in which they will accept retro-authorization requests. This makes understanding payor rules and timely filing of prior authorizations crucial.
The biggest challenges in developing an automated electronic prior authorization solution are the inadequate EDI (Electronic Data Interchange) standards and the low rate of adoption of these standards across the industry. More than 90% of claim submissions and nearly 80% of eligibility and benefit inquiries are done electronically. Whereas an abysmal 8% of prior authorizations are submitted electronically. In fact, electronic prior authorization submissions dropped from 18% to 8% from 2016 to 2017.3
This is primarily due to the inadequate 278 EDI standard which only captures basic demographic information but does not allow for transmitting clinical data required to justify the medical necessity of treatment. The 275 EDI standard, which was designed for transmitting clinical data, is still undergoing revisions and is only used for 6% of document transmittals today.3
At Glidian we have developed an electronic prior authorization platform which eliminates the need to fax or call health plans. We have done this by developing proprietary technology and establishing partnerships with payors directly. Our platform is able to significantly reduce the time spent per case, expedite time to a decision, and analyze missing data that may result in a denial. It also includes reporting features which allow diagnostic providers to analyze prior authorization denials and turnaround times specific to payors and/or services.
By integrating our electronic prior authorization submissions with XIFIN RPM and XIFIN LIS, we’re able to help providers streamline their workflows, prevent denials, and help expedite decisions to make sure patients receive the important diagnostic information they need. XIFIN enables diagnostic service providers to further increase revenue by reducing prior authorization related denials with Glidian's automated prior authorization process and builds on the prior authorization workflow, logic, and document storage already available within XIFIN RPM. Knowing the workflow of prior authorizations starts at the physician’s office, the Glidian application works with XIFIN LIS so that physicians or diagnostic providers can initiate the prior authorization process as early as possible.
To learn more about simplifying prior authorization click here, and be sure to attend our webinar on Thursday, March 14 at 11AM PT.
- Survey: Patient Clinical Outcomes Shortchanged by Prior Authorization. American Medical Association, 19 Mar. 2018, www.ama-assn.org/press-center/press-releases/survey-patient-clinical-outcomes-shortchanged-prior-authorization.
- What Does It Cost Physician Practices To Interact With Health Insurance Plans? Health Affairs, 1 July 2009, www.healthaffairs.org/doi/10.1377/hlthaff.28.4.w533.
- 2017 CAQH Index. CAQH Explorations, www.caqh.org/sites/default/files/explorations/index/report/2017-caqh-index-report.pdf.3