Issue link: https://beckershealthcare.uberflip.com/i/1518055
From Denial to Approval: Winning More Prior Authorizations Starts with Tech-Driven Strategies By Nader Samii, Executive Chairman, nimble solutions, Scott Allen, Senior Vice President, Managed Care Contracting, nimble solutions P reauthorization. Precertification. Prior authorization. One of the most time-consuming, costly, and complex paperchase processes for the healthcare industry goes by many names. e delays to patient care, combined with the authorization acrobatics healthcare providers are expected to perform, continues to create unprecedented and frustratingly high costs. In the uphill battle against insurance "Goliaths," some health systems have the scale to send a message. Fourteen major hospital systems refused to participate in Medicare Advantage's red tape rodeo by opting out of being in-network this year. However, ASCs have limited resources; our industry is like a modern-day showdown between David and Goliath where the little guy rarely wins. While our industry waits for the CMS Prior Authorization Rule to take effect in 2026, there are proactive ways to improve David's probability of success today. The Basics: Utilize Technology to Your Advantage Knowing what we're up against, there's no question that advocating for a patient takes patience and dedication, but it also takes a great deal of planning, including planning for the unexpected. e most common payer denial strategies are based on surgical outcomes you couldn't have anticipated. Creating a database of procedures that require prior approval by payer, including what documents are necessary, and a range of CPT codes for each procedure is the first step in building your prior auth approval strategy. Payers are hedging their denial reasons on your inability to see into the future, but you can outsmart them with this approach. For instance, with CPT 29827 (Arthroscopy Shoulder Rotator Cuff Repair), the extent of damage or necessary procedures may not be clear until surgery begins, even with prior imaging. Review your case history to see what additional codes or what range of codes you should include in your pre-approval process. Unexpected CPT codes and modifiers that were necessary but increased the cost of the surgery are easy to deny. Don't give them the satisfaction. Once you have this information, you'll need to organize it in such a way that it's easy to access and template. Payers oen ask for medical records to prove medical necessity, so our standard practice is to provide all relevant records, including history and physical examinations (H&Ps), operative notes, pathology reports, office visit/ progress notes, and imaging records. Chart management soware and cloud-based storage can help streamline the prior auth process by organizing patient files and preparing documents for electronic submission. Automation can also help flag any missing documents or discrepancies within patient files to ensure accuracy. Always verify insurance eligibility and review patient demographics with your patient before submitting them. Analyzing Payer-Specific Authorization Patterns e next step is to rely on aggregated data to learn the habits and patterns for each of your payers' prior authorization process. Track the outcomes of your payer interactions to determine: • Which procedures take the longest to receive prior authorizations • Which procedures get the most pushback and request for additional documentation • Which procedures tend to require peer-to-peer review For example, if you determine cases with a certain type of implant give you the most hassle, you can review your successes and create templates for each scenario to respond faster. Business intelligence tools that pull data points in meaningful ways will elevate your ability to not just track responses but predict them. You'll also be able to track if payer behavior deviates from historical outcomes. Use Your Data to Track Patient Outcomes and Costs Tracking patient outcomes is paramount for value-based care models and contract negotiations. ASCs typically compare their outcomes and costs with in-patient facilities. However, you can also track the outcomes and costs for patients with prior authorization delays and denials and compare to patients who received immediate approval for the same procedure. Prior authorization delays or denials can worsen a patient's condition, resulting in a trip to the emergency room, a more complicated and expensive procedure, a riskier surgical outcome, or a longer recovery time. ese unnecessary delays typically increase the expenses and the estimated cost of your initial treatment plan. While leveraging this data during the prior authorization process might not persuade a major payer to approve a procedure, it could be of use during negotiations with smaller, local employer plans that are interested in cost savings that deliver quick recovery times for their employees. Data that speaks to the cost of prior authorizations and the negative impact on patient well-being can also be useful to patients who may rely on this information to bring class action lawsuits against insurance carriers. UnitedHealthcare, Cigna, and Humana are currently facing lawsuits for denials. ese patients and their families have a fighting chance against their (and our) Goliaths, thanks to the litigious mountain of paperwork acquired from their healthcare providers. Lastly, tracking prior authorization outcomes can be helpful in determining all costs associated with each procedure and each payer. Track the time it takes to receive each prior authorization, then apply staff and physician salary to that time. Add this amount to all other expenses associated with a case to give you the true cost of each case by payer. en compare that cost to the payer's reimbursement to understand your margins. is analysis may also come in handy when determining your pricing structure and renegotiating contract terms. Artificial Intelligence and Prior Authorization: Challenges and Opportunities When the Centers for Medicare & Medicaid Services (CMS) issued directives urging insurance providers to streamline prior authorization procedures through automation and quicker decision- making, the aim was to enhance patient access to care. However, the insurance industry's adoption of artificial intelligence (AI) to