In the dynamic and complex world of healthcare, payers are consistently on the lookout for effective strategies to streamline operations and mitigate administrative burdens. A pivotal area of focus is the domain of prior authorization. The advent and integration of automated prior authorization technology are revolutionizing this sphere, markedly enhancing efficiency and fostering improved healthcare outcomes. Let’s take a closer look at how automated prior authorization is disrupting the industry.

Exploring the Concept of Automated Prior Authorization

Automated prior authorization is a technological innovation designed to simplify and expedite the process of securing approval for certain medical procedures, medications, or services before they are provided. This advancement is a leap from the cumbersome, error-prone manual methods of prior authorization that have historically plagued healthcare administration.

The Imperative for Automation in Prior Authorization

According to a 2021 AMA survey, 93% of physicians reported that prior authorizations delay patient care. Automating the process can significantly reduce turnaround times and ensure patients receive timely access to necessary treatments. 

When Blue Cross Blue Shield implemented technology to streamline prior authorization, they discovered that approval time was reduced from an average of nine days to an average of less than one day. A significant difference!

Automated prior authorization offers a wealth of benefits including:

Enhanced Time Efficiency: Traditional prior authorization processes are notoriously slow, mired in back-and-forth communications and extensive paperwork. Automation introduces a swifter, more streamlined approach, significantly shortening the duration from request submission to decision.

Cost-Effective Operations: By automating prior authorization, administrative costs, often inflated by manual processing, are substantially reduced. 

Accuracy and Uniformity: Automated systems minimize human errors and provide a consistent approach in the authorization process, upholding high standards of operational integrity.

Strengthened Provider Relationships: Efficient authorization processes lead to improved interactions with healthcare providers, facilitating timely patient care.

Optimized Patient Care: With accelerated authorization, patients gain quicker access to necessary treatments, directly impacting and improving health outcomes.

The Mechanics of Automated Prior Authorization

In an automated system, this process is significantly more efficient. Here's how it typically works:

Integration with Electronic Health Records (EHRs): Automated prior authorization systems seamlessly interface with EHRs, allowing for an efficient and accurate exchange of patient information and requisite medical data.

Algorithm-Driven Decision Making: These systems utilize sophisticated algorithms to evaluate the necessity of a requested service against the payer’s established policies and guidelines.

Real-Time Processing Capabilities: Requests are processed instantaneously, offering immediate feedback regarding the authorization status.

Ongoing Monitoring and Adaptation: Automated systems are designed to continually track changes in healthcare regulations, guidelines, or policies, ensuring up-to-date and compliant decision-making.
 

Exela’s Pioneering Prior Authorization Services

In a healthcare landscape where certain medical services necessitate prior authorization, managing these requests can be a daunting task for providers. Exela’s Prior Authorization solution steps in to alleviate this burden with our sophisticated blend of advanced digitization, automation technologies, and an expert workforce. 

With over three decades in the healthcare industry, Exela's team is not only seasoned but also consistently abreast of current best practices and regulations. Their expertise ensures that prior authorizations are managed correctly, adhering to both plan rules and industry standards.

At the heart of Exela’s service is its cutting-edge technology. Using Robotic Process Automation (RPA) tools, including OCR for swift and precise data capture and programmable rule sets for reliable outcomes, Exela transforms and streamlines the prior authorization process, setting a new standard in healthcare efficiency.

Exela's Prior Authorization solution is designed with user experience in mind. The user-friendly dashboard interface simplifies navigation and management of prior authorization requests. Furthermore, the multi-tenancy environment ensures that the system can efficiently handle multiple clients or departments within a single, streamlined framework.

Central to Exela's Prior Authorization solution is the advanced portal that facilitates bi-directional communication between providers and payers, streamlining the request and response process. This feature ensures efficient and clear exchanges, crucial for timely decision-making and enhancing the overall efficiency of the authorization process

Recognizing the critical nature of time in prior authorization, Exela excels in optimizing cycle times. By creating electronic content and setting up efficient online request platforms for providers, Exela significantly speeds up the decision-making process without compromising on accuracy.

An extensive audit trail is integral to Exela’s services, providing detailed records of all actions and decisions. This feature ensures transparency and accountability, crucial for regulatory compliance and maintaining trust with providers and patients. Learn more about our Prior Authorization solution today!

Looking Forward: The Future of Automated Prior Authorization

The trajectory of automated prior authorization is one of continuous innovation and refinement. Future enhancements may include more sophisticated AI algorithms, deeper integration with various healthcare systems, and advanced analytics capabilities. As technology evolves, so too will the capabilities and benefits of automated prior authorization, solidifying its role as a cornerstone in modern healthcare administration.

Embracing Automated Prior Authorization in Healthcare

Automated prior authorization is more than just a technological enhancement; it represents a fundamental shift towards a more streamlined, accurate, and patient-centric healthcare system. For payers, embracing this technology not only alleviates administrative burdens but also sets the stage for a more efficient and effective healthcare delivery model. In an era marked by digital transformation in healthcare, automated prior authorization emerges as a vital tool in optimizing healthcare processes, promising a brighter future for both providers and patients alike. Ready to elevate your prior authorization process? Reach out to us today!

“It’s the prices, stupid.”

– a group of public health and policy experts in 2003, on

why U.S. healthcare spending is so high

The U.S. spends more per person on healthcare than any other developed nation, and it’s not because ours is higher quality or utilized more often by more people. Rather, it’s because the prices are higher.[1,2]” If only those higher prices correlated with higher life expectancy or lower rates of morbidity (i.e., illness and injury). Alas, they don’t, and the reason is widespread inefficiency in the U.S. healthcare system, and in particular healthcare administrative waste. For example:

- A staggering 60% of the U.S. healthcare industry is currently employed in administration, as opposed to providing patient care,[3]

- The average physician spends approximately half their day on administrative tasks.[4]

Such inefficiencies amount to approximately $935 billion in annual spending. It’s a terrifying figure, even before you consider it represents as much as one-quarter of all dollars spent on U.S. healthcare. With the U.S. still the world’s economic leader[5], the question is, what’s really going on here?

That, along with what can be done to turn things around before losing even more ground, is the focus of this quarter’s issue of Exela’s thought-leadership publication, PluggedIN: Tell Us Where It Hurts: How Tech Can Heal Healthcare. In it, we address the scope of the problem, its historical context, what’s been done thus far to address it, and why, as The Everest Group notes, “inefficiency remains pervasive in healthcare,” despite massive spending on both the part of the government and private interests.[6]Ultimately, we offer solutions—real world solutions ready to be implemented right now.

How do we know? Because we at Exela have the solutions and are ready to deploy them. As Everest notes in its 2019 Healthcare Business Process Automation Solutions PEAK Matrix Assessment,[7]Exela has been successfully prioritizing addressing healthcare’s inefficiencies—our innovative, AI-enhanced and well-priced solutions earning us a place at Everest’s “Major Contender” table in the healthcare space. Those solutions address the full gamut of challenges facing the healthcare industry, including:

• Medical coding
• Information release
• Claims processing
• Claims adjudication
• Provider data management
• Eligibility verification
• Revenue integrity

Our solutions also address challenges common throughout all industries, including:

• Billing and presentment
• Liquidity management
• Human capital management
• Lobby and reception management
• Mail services
• Print services
• Marketing Execution

Perhaps most importantly, however, they address the fundamental first “mile” along any organization’s journey into the process of business process automation/digital transformation: turning the vast and ever-increasing abundance of information in that organization’s possession, in whatever form it exists, into productive assets that can enter automated workflows for cost savings and be leveraged for the increased revenues. That requires both a macro-level of information governance and implementation of a process for enterprise information management. In the healthcare space, Exela offers comprehensive health information management solutions, tailored to healthcare’s specific challenges and goals.

PluggedIN is Exela's thought leadership publication, providing fresh insights from the cutting edge every quarter. Subscribe. Plug in. Upgrade your mind.

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[1] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.3.89

[2] https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05144

[3] https://www.americanprogress.org/issues/healthcare/reports/2019/04/08/468302/excess-administrative-costs-burden-u-s-health-care-system/

[4] https://www.focus-economics.com/blog/the-largest-economies-in-the-world

[5] https://www.exelatech.com/report/healthcare-business-process-automation-solutions-peak-matrixtm-assessment-2019

Nearly a decade ago, Harvard economist, David Cutler, famously called out Duke University Hospital for employing 1,300 persons to administer billing for only 900 beds. Apparently, that’s what it took in light of the many disparate requirements imposed by multiple payers (patients, insurance companies, the government) in every transaction. Nearly a decade later, healthcare automation offers efficient alternatives in billing as well as many other business processes.

Automated claims processing

As a threshold matter, automating healthcare solutions requires effective health information management. Health information management holds significant promise with regard to eliminating delays and denials in the claims process, which impact payers, providers, patients, and public health in general. Effective health information management not only directly addresses known issues in the claims workflow, but it is also a crucial first step in automating points along that workflow for optimal use of human capital, ROI optimization, and enhancing employee- and patient/consumer-experience.

To wit:

- For every process a payer or provider automates, there’s less need for manual intervention.

- Automated processing enables full visibility throughout the process.

- Intelligent data analytics tools help ensure efficient compliance efforts and enhance data privacy, routing related documents for the most efficient and appropriate reconciliation.

- Predictive analytics tools help providers and payers plan for uncertainties, including appeals and resubmissions.

By way of example, Exela’s deployment of our custom, self-service, rule-based healthcare solutions saved a top 10 payer an impressive 35% in the cost of processing claims and amounted to a 50% reduction in cycle time and a 20% reduction in resubmission rates. In addition, increased transparency for payers, providers, and members vastly improved employee- and patient/member-experience and reduced the demand for customer-service interactions. You can learn more in this case study.

Automating payments

Automating billing can be a game-changer by:

• Reducing the number of persons dedicated to the process, reducing time spent, and errors associated with, manual keying.
• Unifying payment data from multiple channels such as paper checks, debit transactions, collection procedures, etc.
• Enabling an improved patient communication strategy.
• Introducing other valuable efficiencies into the billing process such as HIPAA-compliant lockbox solutions.

In fact, we at Exela know how valuable such steps can be because we’ve seen it first-hand in solutions we’ve provided to our customers. For example, in the case of a major academic health system whose outdated payment operations had been mired in manual, error- and loss-prone processes, we deployed our Patient Financial Services suite to streamline information ingestion, facilitate communications, and optimize workflows, with the result being a 25% reduction in full-time employees needed for these operations and a 30% increase in collector efficiency. You can read more about it in this case study.

In addition to streamlining claims by avoiding denial of payment through improved coding, delivery of clean claims, and facilitating all related inter-stakeholder communications, automation can optimize revenue integrity through, among other things, data mining for the purpose of predictive analytics and revenue forecasting, all in the service of identifying and recovering all amounts in the most effective and efficient manner. For example, when a large healthcare system wanted a way to maximize reimbursement under their many payer contracts (all of which had different requirements, terms, and conditions), Exela deployment of its healthcare automation solutions resulted in 99.6% accurate reimbursement and identified 98.4% of underpayments and calculated predicted reimbursement under all payer contracts. “We look forward to continuing our relationship with Exela for years to come,” commented the customer in this case. “The contingency, success fee based engagement has provided an extremely positive, financial bottom line return, while requiring minimal staff time on our part...”

In addition, our medical lockbox solutions support providers in managing (and reducing the costs associated with managing) a high volume of receivables payments. And our newly-launched Real Time Payments solution can streamline the collection of remainders from patients using secure messaging and convenient payment options (via text message with payment options).

Automating accounts payable

It’s not just the core businesses of stakeholders that benefit from automation. For example, another of Exela’s customers, a national urgent care provider, had been processing more than 50,000 vendor invoices per month, resulting in lost documents and delayed payments to vendors, before turning to Exela to fully automate its burdensome paper-based workflow. In addition to streamlining payment to vendors and lowering the incidence of defaults and discrepancies, the user-friendly interface equipped the provider with the tools needed to readily address discrepancies if they arose and permitted the provider’s vendors to check invoice status online.

In the case of a major pharmaceutical company with a global footprint and driven by constant research and development, Exela was able to harmonize, digitize, and automate the more than 50,000 incoming invoices from 40 different business areas in 19 different countries through a custom-tailored combination of digitization services, data extraction, reporting, and remittance.

Automation Enrollment

Open enrollment is a payer-specific issue, and it’s always challenging. With ever increasing pressure to outperform the previous year’s results, there’s always a need for process innovation to meet increasing demands. Pressures are compounded by a short enrollment timeframe and employees who find the process confusing. The result is numerous queries and insufficient enrollment documentation. A large insurance company customer of Exela had been struggling with this scenario to the point that its satisfaction scores with providers and members were being severely impacted. Exela designed a universal intake and workflow solution to manage all the various modes of communication between the payer and the employees/potential members. In less than 90 days, Exela delivered 240,000 enrollment installations a month at a quality of 99.5% with significant cost savings in the form of reduced call volume and reduced pending items. Customer satisfaction soared.

Benefits to patients

The administrative complexity of the U.S. system also burdens patients, whether they are deciphering bewildering bills or shuttling records between providers. Three-quarters of consumers report being confused by medical bills and explanations of benefits. A Kaiser Family Foundation survey of people newly enrolled in the health insurance marketplace found that many were not confident in their understanding of the definitions of basic terms and concepts such as “premium,” “deductible,” or “provider network.” Insurers and employers spend an estimated $4.8 billion annually to assist consumers with low health insurance literacy, according to McKinsey.

For the full story on how technology can solve costly inefficiencies in the health industry, be sure to check out our Q4 Edition of PluggedIN: Tell Us Where It Hurts: How Tech Can Heal Healthcare.

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Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511963/

https://www.streamlinehealth.net/HIM-blog/revenue-integrity-can-organization-best-achieve/ https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/promoting-an-overdue-digital-transformation-in-healthcare

Digital transformation in healthcare continues to be a key topic in many healthcare leaders' minds. Healthcare providers of every size face the same challenge of improving patient care and engagement while managing costs. However, many obstacles create complications including limited staffing, outdated systems, payer contract complexities, and more. By embracing digital transformation, healthcare providers can begin to tackle these obstacles and accomplish their goals for the future.

Digital transformation in healthcare affects many aspects of the business from freeing up resources that can be devoted toward patient care and increasing patient engagement to improving operational and financial efficiencies. With AI, automation, and technological advancements, the healthcare industry stands to gain improved processes, quicker payments, and fewer claims denials.

Digital Transformation in Healthcare Starting with Automated Claims Processing

Claims management and processing is a major operation in need of digital transformation in healthcare. This is often a thorn in healthcare providers' sides because of its complexity. Claim denial rates are between 6% and 13%, which eats away revenue.

These statistics highlight the importance of submitting clean claims right from the start. However, this is easier said than done especially when relying on manual processing and outdated systems. Many healthcare claims are being denied for simple reasons such as a spelling error, incorrect coding, missing patient identify information. Given that healthcare organizations' resources are stretched thin, it makes sense that claims processing would be vulnerable to human error.

Once again, digital transformation in healthcare can step in and smooth the process. Exela is a leading claims processing provider with a solution that enhances claim processing by unifying data from all incoming communication channels, performing pre-submission checks to create clean claims, and intelligently routing correspondence for optimal processing using automated decisioning. Exela’s Healthcare Claims Processing solution reduces denials and resubmissions by applying business rules to produce clean claims prior to submission. Using automation and artificial intelligence, Exela increases transaction processing rates and accuracy while reducing manual processing and rework.

Take Complex Claim Processing Further

According to a 2021 CAQH report, only 21% of medical administrative transactions are digital while the rest are paper. Exela leverages exclusive vendor contracts with leading health plans for complex paper claims processing.

Embrace digital transformation further with Exela's PCH Global solution, a powerful digital platform that not only provides a single point of access for claims management but provides a central bridge between all parties including the provider, payer, and patient.

PCH Global promotes clean claim submissions by identifying certain-to-denied claims, thereby improving first-pass rates. Its iterative feedback loop technology helps the system continuously learn and improve to identify errors enabling proactive claims management with system flexibility as your contracts change.

Finally, the system automatically tracks and records any addition, deletion, or modification to transactions along with user reference and timestamps providing clear audit trails and ensuring full compliance.

Digital Transformation of Remittance Payments

The 2021 CAQH report determines that the healthcare industry could save 48% of annual spending by transitioning to fully electronic transactions. Manual processing significantly slows down operations especially when human errors are taken into consideration. Automation streamlines this process reducing errors, posting payments quicker, and improving overall efficiency making it a terrific place for digital transformation in healthcare.

Exela's Medical Lockbox simplifies the healthcare payment process by digitizing and automating manual, paper processing tasks. Using a state-of-the-art scanning platform and intelligent OCR/data capture technology, Exela’s Medical Lockbox solution converts paper EOBs from any source into 835, electronic remittance files, payment reconciliation and posting to the healthcare organization's medical billing system. By streamlining the payment path, Exela’s Medical Lockbox solution reduces the time it takes for payments to post and allows quicker access to deposited funds. Submitting secondary claims or patient billing, depending on the patient’s coverage, makes the payment cycle faster from Primary, Secondary, Tertiary or Patient payments.

Not only does Exela's Medical Lockbox streamlines payment processing, but it also features a web-based denial management tool designed to increase the recovery rate on denied claims. This web-based management tool presents the original claim and all related remittance information in a single view simplifying the process for users to adjust the claim, bill the patient, or appeal the denial. Insights are gleaned through reimbursement metrics presented within Exela’s Medical Lockbox’s configurable reporting function. These insights are valuable with billing system audits and contracts negotiations.

Automated Contract Management

Healthcare payer contracts vary greatly, each having different policies, regulations, and parameters. The contracts of each insurance company are often revised and updated annually so healthcare organizations need to renegotiate several payer agreements every year.

Keeping track of the current contracts and any annual updates is an enormous task that burdens healthcare resources. Without a handle on contract management, healthcare organizations are vulnerable to underpayments which affect their bottom line. Contracts and underpayment management are yet another place where digital transformation in healthcare is needed.

Exela’s Revenue Integrity solution automates the contract management process, document scanning, indexing, profiling, loading and maintaining all third-party payer agreements. Agreement terms are tracked and providers are presented with notifications of important dates as well as amendments and updates. Instead of using limited resources to keep track of contracts, automation is ready to step in.

Exela’s Revenue Integrity solution also offers predictive contract modeling that provides accurate reimbursement calculations for current and future contractual agreements. By providing multiple scenarios and utilizing the most recent one-year patient data set, the platform presents the net dollar and percentage increase or decrease.

This solution also identifies retrospective, current and prospective underpayments from all contractually obligated third-party payers.

Summary

Digital transformation in healthcare opens many doors and it’s time providers embrace the opportunities available to them. AI and other technologies are ready to streamline antiquated processes, increasing efficiency and accuracy while freeing up personal time.