It’s no secret that burnout is a struggle in the healthcare industry, and the complicated, time-consuming pre-licensing process is one of the contributing factors. In fact, the U.S. Surgeon General addressed this during a consultation this summer aimed at reducing clinician burnout, suggesting effectiveness in delegation tasks. prior rights.
Technology can enable electronic pre-authorization, a tool in usage management designed to automate processes and provide faster approval and feedback. This type of technology may be growing as a necessity, with 84% of physicians said an increased need for services and drugs required prior authorization.
Dr. David Sand is the medical director of population health company ZeOmega. We interviewed him to talk about the role technology plays in reducing the administrative burden for both payers and providers. He shares pre-authorization challenges he’s observed in his experience and explains how electronic pre-authorization can help alleviate these problems.
Q. What are the pre-authorization challenges for healthcare providers that you have observed over the years?
ONE. The first question a provider typically asks when reviewing a test or service for his or her patient is, “Does this require prior authorization?” Vendors are legitimately involved because failure to obtain the required pre-authentication often results in payment refusal.
While similar, each payer has a different list of procedures, services, and DMEs that require prior authorization, and knowing if the list the office has is up-to-date is challenging. . The next issue is keeping track of the various processes, payer portals, fax numbers, passwords, and all the other non-technical details needed to submit the request.
Regardless of the size of the patient pool in a practice or how many times a patient’s coverage changes, the practice must maintain an accurate and current inventory of requirements and expenses. details of each payer.
Statistics regarding the amount of office resources must be reserved for the pre-authorization process. Often, a procedure-oriented practice, such as surgery or GI, will have a full-time staff member assigned to the procedure. Understandably, this is a significant burden on practicing business.
The need to demonstrate the medical necessity of a prior authorization request is challenging on two fronts. First, having gone through medical school and residency training, most providers feel they have the right clinical and specialist knowledge to know what’s best for the patient sitting in front of them. surname.
Second, although clinical information is included in the EHR, it often needs to be extracted and sent with the request. In many cases, the information sent is not enough and time and resources go back and forth between the office and the payer as additional requests and additional documents are exchanged until authorization is obtained. before.
Q. How does the complex pre-authorization process contribute to burnout in the healthcare sector?
ONE. Service providers train and dedicate their lives to healthcare to help their patients, not tending to carry out the administrative and business tasks imposed on them. While younger vendors may step into practice with a better idea of the non-technical tasks they have to deal with, they may still underestimate the burden.
Providers who have begun to practice before the emergence of managed care, clinical pathways, management of use and optimal recovery guidelines, and “imposition” of best practice and requirements based on conceivable evidence that their efforts to gain clinical expertise are being ranked second – as judged by people who have never really cared for a patient, never received a call call in the middle of the night or family time is interrupted to run to the clinic.
In addition to this sense of devaluation, suppliers increasingly recognize the distinction between profession and the drug business. The two are very different, and it is necessary to pay attention to both.
As downward pressure on reimbursements has increased, the additional financial costs of running the business have increased. Healthcare professionals are smart enough to do “mental math” – compare their paychecks with the effort required, while also looking at their friends and former classmates who have chosen them. different professions.
For years I have been told that drugs make you a boring person. Patients want this in their provider – whether they realize it or not. They want a doctor who spends his time studying and one hundred percent focusing on practicing medicine rather than playing softball, traveling, and going to weekend barbecues with the neighbors.
Most doctors will tell you that they gave up their hobbies for a while in medical school with the intention of continuing them after they had practiced – only they never did.
Years ago, the pursuit of medical excellence was enough to satisfy them. The respect given to doctors and nurses in the past, the close friendships and shared experiences of those in the healthcare field, and yes, compensation and lifestyle, historically worth the trade-off. No more.
Q. How does technology enable electronic pre-authorization, and what does technology do to the process?
ONE. The terms I hear most often when talking to healthcare executives are: automation, efficiency, optimization. Pre-authorization is a labor and resource intensive process. It is strictly regulated in government-funded health plans (e.g., Medicare Advantage, Managed Medicaid) and these regulations are passed on to health care providers.
In general, suppliers do not appreciate any value from these provisions, but instead complain that the payer does not accept their necessary bargaining end.
To the extent that automation improves any functionality that drafts pre-authorization, both the provider and the payer must experience the effects. The efficiency brought by technology tools will improve aspects of the pre-authorization process, such as the time from submitting a request to making a decision and communicating that decision to the physician and physician. patient, as well as the level of effort required to support that turnaround time.
Electronic pre-authorization brings together previously disconnected technological tools while creating transaction efficiency.
The review hierarchy and rules and guidelines include submission and communication channels such as portals, summary of medical records from the EHR, containing documents that demonstrate medical necessity, all require human interaction in its current state, and most if not all of this intervention can be automated through electronic pre-authorization technology.
Q. How does electronic pre-authorization help reduce burnout?
ONE. Many of the time-consuming and financially burdensome processes involve submitting a pre-authorization request, receiving it, the back-and-forth process to gather supporting documentation, manual review of regulations, and providing guidance, issuing and communicating decisions, peer consultation, appeals, and submitting additional information, all of which contribute to burnout.
These are activities that are physically, financially, and emotionally draining to health care providers and considered by everyone to be of no value to health care. Electronic pre-authorization automates virtually every step in the process and creates efficiencies that take the financial burden off – and much of the physical workload.
During this process, frustrations inherent in the process are relieved and greater satisfaction is achieved with the provision of near-instant answers – usually while the patient is still sitting with the doctor. his officer. Essentially, electronic pre-authorization provides a better product with less effort and cost.
The resulting improved provider, patient, and even payer satisfaction by removing the pain points of traditional pre-authorization begins to rebalance the forces described above and restore offers the joy and rewards that most healthcare providers expect when they initially pursue a career in medicine.
Twitter: @SiwickiHealthIT
Email the writer: [email protected]
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