Looking to Improve Prior Authorization Workflows?
There are 3 basic things to consider when striving to improve prior authorization workflows; The What, The How, and The Who. Let’s first talk about the what.
The What
The first thing to consider when setting out to improve your prior authorization workflows is understanding the what of the submissions. One of the first steps to help you begin to understand the workflow is to get a handle on what services require prior authorizations for which payers. I know that this can be incredibly daunting, but those organizations that at least begin to create internal rules, often done in a spreadsheet, can have a place to begin to work. By getting your leads and your staff on various access teams, can help identify problem areas and define rules to help both existing and newly onboarded staff have an idea of what services require authorizations. We know that this can be a bit of a nightmare since payers are always changing the rules, but you have to start somewhere and build “tribal knowledge” that can be shared and updated.
The How
Knowing how your payers want to receive authorizations, whether it is fax forms, a phone call or a specific web portal for the submission is crucial in having a more efficient prior authorization submission workflow. There are a variety of methods that people have figured out over time that work for them, but all too often we have staff resorting to faxes and phone calls even though there is a potentially faster submission and approval process via a web portal.
The Who
Given that 80% of prior authorization submissions and verifications are manual, we see a substantial amount of delays and errors that occur. More importantly, where there are different teams that are responsible for different workflows, for example, authorization initiation/submission vs verification, there can be a lack of clear delineation of roles and responsibilities and poor accountability. This often leads to gaps in handoffs which further delays approvals and care. For complex organizations especially, we recommend having collaborative discussions between teams to define roles and expectations and be sure that they are working together. Of course, having a centralized platform like Valer that provides real-time visibility can help tremendously.