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Exploring the Future of RCM Automation: Latest Processes and Technologies for ASCs to Optimize RCM

As ambulatory surgery centers (ASCs) strive to improve revenue cycle management, the prior authorization process presents challenges due to the increasing complexity of payer requirements. ASCs may experience delays in receiving prior authorization approval, which can lead to postponement or cancellation of scheduled procedures, impacting patient satisfaction and revenue. 

Payers may reject prior authorization requests due to inadequate documentation, leading to additional administrative work and potential revenue loss for ASCs. Inefficient workflows and communication between ASCs and payers can lead to delays and denials in the prior authorization process, affecting revenue cycle management. 

In this blog post, Lisa Rock, President of nimble solutions, shares tips on optimizing the prior authorization process. Continue reading for Lisa’s key takeaways.

Can you explain the prior authorization process in the simplest terms?

Prior authorization is a process used by insurance companies to determine if they will cover a particular medical treatment or procedure. 

The prior authorization process can vary depending on the specific requirements of your insurance company and the nature of the treatment or procedure in question. It can sometimes be a lengthy process, but it is designed to ensure that patients receive appropriate and medically necessary care while also helping to manage healthcare costs. 

What costs are associated with a manual prior authorization process?

We know time is money and the manual prior authorization process requires both.  

A survey from the American Medical Association (AMA) found 40% of physicians have staff members who work exclusively on prior authorization requests. Physicians and their staff spend an average of 20 hours per week to complete over 40 prior authorizations per physician.¹ That’s a lot of payroll dollars spent on just one aspect of the revenue cycle. 

A health system with 80 outpatient sites crunched the numbers to discover that managing prior authorizations cost them $18.2 million in 2019. Prior authorization delays that caused patients to reschedule or cancel booked procedures added up to $3.6 million in lost revenue.²

Human error, changes in payer rules, and inexperienced staff members also contribute to prior authorization errors that typically end up as claim denials, further impacting your time and cash flow.  

Even a 2% error rate in the prior authorization process can cause significant revenue loss for ambulatory surgery centers.   

How can ASCs leverage automation to improve authorizations? 

There are several automation processes available to ambulatory surgery centers (ASCs) to improve the prior authorization process.

To cut down on the manual tasks and the time associated with prior authorizations, ASCs are utilizing electronic prior authorization software and cloud-based tools including:

Electronic Eligibility Verification: allows ASCs to check patient insurance eligibility electronically in real-time to help identify the need for prior authorization and reduce the chance of claim denials.

Electronic Prior Authorization (ePA): involves submitting prior authorization requests electronically through a secure web portal or clearinghouse, reducing the need for manual faxing or phone calls and reducing the time and effort required to obtain authorizations.

Real-Time Benefit Check (RTBC): provides real-time information on a patient’s insurance coverage, including prior authorization requirements and associated costs. This can be integrated into your electronic health record (EHR) systems.

Robotic Process Automation (RPA): RPA is a technology that uses software robots to automate repetitive tasks. RPA can be used to automate the manual tasks involved in the prior authorization process, such as data entry and document retrieval.

Artificial Intelligence (AI): tools such as machine learning algorithms can automate the prior authorization process by verifying insurance eligibility, identifying which patients need authorization, and automatically submitting requests to payers.

As you can see, there are several technology solutions available to streamline the prior authorization process. Request a revenue assessment to see where you can make impactful changes.

What’s the best strategy to process prior authorization claims?  

Prior authorization is a process used by insurance companies to determine if a particular medical treatment or procedure is medically necessary before approving coverage for it.

The best strategy for processing prior authorization claims can vary depending on the specific requirements of the insurance company and the nature of the medical treatment or procedure in question.

However, some strategies that can help streamline the prior authorization process include:

Gather all necessary information: Ensure that you have all the necessary information needed to complete the prior authorization request, including the patient’s medical history, relevant lab results, and any supporting documentation required by the insurance company.

Submit the request in a timely manner: Many insurance companies have strict timelines for submitting prior authorization requests, so it is essential to submit the request as soon as possible to avoid delays and ensure that the request is reviewed in a timely manner.

Utilize technology and automation: There are a variety of software and automation tools available that can help streamline the prior authorization process, such as electronic prior authorization (ePA) systems, which can reduce the time and effort required to complete the process.

After submitting a prior authorization request, it is important to follow up regularly with the insurance company to ensure that the request is being reviewed and processed. This can help to identify any potential issues or delays and allow for timely resolution. 

As a healthcare provider, it is important to advocate for the patient and ensure that they receive the care they need. This may involve advocating for the approval of a prior authorization request or exploring alternative treatment options if a request is denied. 

What are the financial benefits of automating prior authorizations?

The financial benefits of automation are clear: by reducing the number of manual tasks involved in prior authorizations, you’re decreasing labor costs and improving overall efficiency.   

By reducing the time and effort required to obtain prior authorizations, healthcare organizations can see an increase in revenue. This is because automated systems can help providers get prior authorizations more quickly, allowing them to see more patients and bill for more services. 

Automating prior authorizations can help healthcare organizations streamline their revenue cycle management processes. Automated systems can help ensure that prior authorizations are obtained in a timely and efficient manner, which can help prevent denials and delays in payment. 

Automated prior authorizations can also improve patient satisfaction by reducing wait times and delays in care. Patients who receive timely and efficient care are more likely to be satisfied with their healthcare experience, which can result in increased loyalty and referrals. 

Are you looking for ways to improve your revenue cycle management? Take the first step towards optimizing your revenue cycle process by requesting a revenue assessment from our team of RCM experts. Request a demo.