There’s been little good news out of Washington, D.C. lately on the healthcare front. But with the future of Obamacare still uncertain (even though the House has passed replace and repeal), there’s at least some good news on the web technology front for an industry that spends between $330 billion to $597 billion per year on insurance and billing related-activities. One of the most tedious but essential of these tasks—obtaining authorizations from healthcare payers—can now be carried out almost completely by automation and machine learning, with practically zero human intervention.
Just in time, too, as hospitals are increasingly charged with obtaining these authorizations on behalf of both employed and contracted physicians. While taking on the bulk of this responsibility conceivably reduces a hospital’s denial risk, if done conventionally hospitals could end up spending a fortune on the required staff time. That’s because while gaining control of the process better assures the right steps will be taken to obtaining authorizations, the steps themselves remain cumbersome and time-consuming.
Requesting a single authorization, for example, typically takes at least 15 minutes. It requires a staff member to visit a payer’s website, then copy and paste a significant amount of non-clinical and clinical patient data into numerous fields. For large multi-facility integrated delivery networks the process can require delegating hundreds of employees, or writing significant outsourcing checks. It’s also inefficient in that clinical specialists are put to work requesting even routine services that call for little clinical detail or knowledge.
Near “touchless” authorizations
Now hospitals no longer have to put their clinical specialists to work on such mundane tasks. Authorized web crawlers can instead log-in on the payer’s website on behalf of the provider, using the provider’s credentials, to make an authorization query. With the addition of a robust rules engine that draws on hundreds of thousands of authorization rules, the requests can be configured to auto-populate patient data, saving even more manual work. Of course, some manual clinical data input is still required, but significantly less than before.
As for obtaining status of these requests, the same web crawlers can retrieve status on countless requests at once, standardize the answers and route this information to the hospital’s system of choice. For example, authorization queries that indicate “approved” can immediately and automatically be routed to the hospital’s registration and scheduling systems. Those that are deemed “denied” can be routed, by reason, to the authorization specialists to bring to resolution.
For even more efficiency, worklists can show which scheduled procedures still require authorization from payers, and even integrate these reminders directly in the HIS system.
So there you have it—a practically touchless authorization, with much of the first half and all of the second half automated. Now volumes of authorizations can be processed in a fraction of the time manual efforts took. So why hasn’t the industry made an industry-wide shift to this new way?
Application fatigue—and APIs to the rescue
Although hospitals can and do use the above programs as standalone capabilities, or integrated into enterprise-wide medical records systems like Epic, many others are hesitant to sign on to yet another application implementation. The reality is that hospitals have been in the midst of one information technology deployment after another for a decade or longer. There is a sense that there are too many applications and systems to manage, even if some clearly pay off in new efficiencies.
In response, technology vendors are offering APIs to their products and services—including for authorization automation. By bringing representational state transfer (REST) frameworks for developing web services and projects to the revenue cycle, such APIs drive accurate and actionable payer information directly into a healthcare organization’s existing systems, as part of nearly any workflow, for prior authorizations, patient eligibility, medical necessity, pre-service patient collection and related revenue cycle management process. (Of course, APIs can also be used to create a payer intelligence feed into new applications.)
Hospitals have always needed access to the right information from payers at the right time, but never more so as they face rising levels of patient debt. Thankfully—and unlike the days of old—throwing more staff at this newest challenge need not be the response. Instead, APIs, automation and other smart technologies offer a way to stay financially healthy without becoming administratively weary.
Heather Kawamoto is vice president of revenue cycle management for Recondo Technology.Favorite