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Every provider’s top priority is to offer the best care to patients as quickly as possible. As healthcare costs continue to rise—and remain far higher in the U.S. than in any other developed country—providers are also focused on how to reduce the total cost of care for patients. Unfortunately, many barriers to fast, high-quality care are built into the way we traditionally practice medicine.

One of the places where providers struggle with delays is prior authorization (PA). This process remains archaic and cumbersome for most payers. Significant delays frustrate patients and care providers and can even put patients at risk of not receiving timely care while waiting for approval.

The technology for electronic prior authorization (ePA) exists today. Implementing it allows providers to focus attention on patients instead of paperwork.

The Administrative Burden of Traditional Prior Authorization

Many insurance plans will not cover procedures or treatments without a prior authorization. In a 2020 American Medical Association (AMA) survey opens in a new tab, practices reported filling out and submitting about 40 PAs each week per physician. Each one takes an average of 25 minutes, which totals 16 hours of work each week. If a single staff member were assigned to that work, it would take two full business days every week to complete the job for just one provider.

About 40% of physicians have a staff member whose only job is to work on PAs.1 In small clinics, this burden can be extremely high. Either you pay more overhead to hire more employees, or your staff has less time to help patients. Neither is a comfortable option.

Why Haven’t PAs Gone Digital?

In a typical PA process:

  • The provider’s office determines what form(s) are necessary based on the patient’s insurance coverage.
  • They fill out the form(s) and send them to the payer via fax or online.
  • The insurance company reviews the request and determines whether it meets the plan guidelines for covered treatment.
  • The insurance plan either approves or denies the request and notifies the patient and provider’s office by fax, phone, or mail.
  • If the request is denied, you can fill out and submit an appeal, then wait for someone to review that information and get back with a decision.

In a 2019 American Society for Radiation Oncologists (ASTRO) survey opens in a new tab, only 7% of PA requests were resolved in less than one day. Almost two-thirds (63%) took four or more days.2

The medical field is known for innovative and life-saving treatment, but often falls behind in adopting and implementing new administrative and practice management technologies like ePA. Right now, only 13% of 184 million PAs in the U.S. are fully electronic.3 Digital submission and approval could significantly reduce these delays, but there are several barriers:

  • Data consistency. Providers need an efficient way to identify what to include in the PA request.
  • Federal standards. There are no federally mandated standards or requirements for attachments when you submit clinical information.
  • Integration.Clinical and administrative systems often don’t connect, so providers have to pull information from a clinical EHR and submit it for payers to enter into their administrative system.
  • State laws. Some states still have laws that require PA submission by phone, fax, or secure mail.
  • HIPAA concerns. Providers might not know that the 5010X217 278 Request and Response opens in a new tab requires health plans to offer full ePA.
  • Vendor limitations. Few vendors offer a fully automated ePA solution.

How PINC AI’s ePA Can Change Things

Premier’s PINC AI™ clinical intelligence gives providers the tools to submit and receive prior authorization in a matter of minutes, all without the need for fax machines, phone calls, or hiring entire staff positions to handle prior authorization.

How it Works

With PINC AI™ clinical intelligence, ePAs are simple. First, the physician places the order. The cloud-based system verifies insurance eligibility based on the applicable payer rules, then a series of algorithms determine whether the procedure is medically necessary. If there isn’t enough information to make that determination, the system prompts the physician to answer a few more questions. Once everything is verified, the provider and patient get an authorization number.

In rare cases where the software cannot complete an electronic prior authorization, the physician’s office will follow the “normal” procedure for submitting those requests by fax or phone to the payers.

PINC AI’s ePA software offers several advantages to providers, including:

  • Seamless integration into existing workflows.
  • Execution at the point of care, without the need for any additional staff or work.
  • Automated queries for both benefits and eligibility.
  • Advanced algorithms for determining medical necessity based on payer rules.
  • Pulls information straight from the EHR without any manual data entry.
  • Automatically reviews and alerts if there is missing information.
  • Instant approvals that used to take several hours or days.
  • Payer validation of the system.

Find Out How Our PINC AI ePA Tools Can Benefit Your Practice

With ePA tools through PINC AI™ Clinical Intelligence, you can help eliminate hours of paperwork and frustration from trying to complete thousands of PAs for every physician, every year. It helps reduce overhead costs to your practice by eliminating the need for PA-specific staff and helps you focus on providing the best care to your patients promptly. Read our E-book opens in a new tab to learn more about how Premier ePA can help you.

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Stanson Health
  1. 12020 provider survey by the American Medical Association available at: https://www.ama-assn.org/system/files/2021-04/prior-authorization-survey.pdf Accessed January 2022.
  2. 2019 American Society for Radiation Oncologists (ASTRO) survey available at: https://www.astro.org/ASTRO/media/ASTRO/News%20and%20Publications/PDFs/ASTROPriorAuthorizationPhysician-SurveyBrief.pdf Accessed January 2022.2
  3. 2019 CAQH Index, Conducting Electronic Business Transactions: Why Greater Harmonization Across the Industry is Needed. Available at: https://www.caqh.org/sites/default/files/explorations/index/report/2019-caqh-index.pdf?token=SP6YxT4u Accessed January 2022.