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Automate Prior Authorizations to Save Time and Money

An image of a patient and home caregiver representing the time and money Prior Authorizations create.

Prior authorizations were created to cut costs faced by payers and to reduce the number of unnecessary surgeries, tests, and medications. In theory, it seems like a logical concept that its benefits would trickle down to both patient and provider. In practice, however, based on years of provider feedback, many providers feel it has served to aid payers.

Prior authorization practices currently cost the healthcare industry between $23 and $31 billion each year per the Journal of the American Board of Family Medicine. In fact, when asked by a member of the American Medical Association private sector advocacy group, physicians reported that increasing the number of prior authorizations necessary to cut costs and unnecessary treatments is one of the least effective methods of doing so. The American Medical Association also states that on a scale of effectiveness, the only other measure that the same physicians rated lower was patient cost sharing. There is no denying it; manual authorization processes can be tedious and bothersome.

The number one complaint coming from providers: prior authorizations favor the corporate side of healthcare. It may appear that way, however if one digs a bit deeper it becomes increasingly obvious that there are benefits to requiring prior authorizations. While providers and their staff may feel as if prior authorizations slow the process down, prior authorizations are necessary. With an effective automation system in place, they become much easier to request, obtain, document and track.

Thanks to technology and streamlined automation, many prior authorizations that would have previously required time-consuming manual paperwork from medical personnel, can now be completed with a click of a button. Auto-adjudication efficiently expedites utilization management tasks associated with it by leveraging the organization’s standard guidelines using automation.

Most automation systems now allow you to perform multiple tasks in real-time. A provider can simultaneously:

  • check a patient’s eligibility
  • submit requests for prior authorizations
  • send out automated approval letters
  • facilitate payer-provider collaboration for referrals
  • automate referrals of approval requests
  • ….and more

This makes the delivery of care much more efficient for the provider and payer. It streamlines the process for everybody involved. With less confusion comes an increased level of accuracy – which in turn generates a faster turnaround time for authorization approvals.

Because the cost of healthcare is steadily rising and to mitigate that cost, everyone involved is continually implementing cost-saving measures. Quicker turnaround time results in cost savings for the patient, payer and provider. As healthcare continues to evolve around cost savings models, prior authorization has become one more vehicle to achieve this goal.

Auto-adjudication is just one technique being used to strengthen utilization management as we know it. It may even be a major player in freeing up a significant portion of the $23 – $31 billion being lost in the healthcare industry each year. Providers and health plans should be focusing on improving patient care while developing cost-saving techniques. By automating prior authorizations, this helps to buy back precious time. Find out how MedCompass® can help your organization streamline your pre-authorization process.

Disease Management Partnering with Technology

Am image representing the partnership between disease management (DM) and technology MedCompass creates.

Disease Management is an enormous task for payers and providers. To defeat the challenges faced by society in managing patient illness, many different types of technology and personnel are needed to make a measurable difference. Healthcare thought leaders have defined a term that helps break down a strategy to conquer these challenges. This term is often referred to as “Triple Aim”. According to the Institute for Healthcare Improvement (IHI), the Triple Aim is comprised of three specific goals meant to enhance care at every level. The IHI states that those three goals are:

  • Improving the patient experience of care
  • Improving the health of populations
  • Reducing the per capita cost of healthcare

With an aggressive disease management strategy, each one is attainable. The CDC states that chronic diseases account for 7 out of 10 deaths every year. Treatment of patients with chronic diseases account for about 86% of America’s healthcare costs. Due to the consistent rise of healthcare costs, patient count, and chronic disease diagnoses, we must face these issues head on with all three goals in mind. From provider to insurer, disease management technique matters.

Thanks to the Healthcare Readmissions Reduction Program (HRRP), hospitals are now seeing reduced payments for an excessive rate of readmissions. This puts more pressure on providers to manage illnesses and chronic diseases more effectively. Effective and measurable disease management is an integral component of the care coordination toolbox and has quickly gained merit for its capabilities.

Let’s discuss a specific patient named Sally. She is a smoker who was diagnosed with diabetes a few years ago. Her smoking habit and poor diet causes her blood sugar to skyrocket. Her medical chart suggests she has been admitted to the hospital multiple times over the span of a few years due to diabetic complications. With a disease management program powered by an actionable care management software solution, she is flagged as someone who can benefit from some additional care management. Sally is then assigned to a case manager who contacts Sally to learn more about her lifestyle habits.

A personalized care plan is then developed based upon what the case manager uncovers during her interaction with Sally, enabling the case manager to create a custom treatment plan based on Sally’s history, assessments and medications. Alerts are then tailored to Sally, with real-time notifications of changes to her critical values.

Sally is given nutrition plans that she incorporates into her daily life and attends smoking cessation classes. Her risk factors for diabetes complications decrease significantly, as do her chances of readmissions, continued unplanned testing, and increased trips to the doctor. Now, not only is Sally healthier, but she has received higher quality, more comprehensive care, while her healthcare costs have decreased.

Similar issues are faced by insurers, with slightly different goals in mind. When a patient continues to be readmitted for the same issues, especially when those issues stem from a manageable illness or disease, insurers look for new and innovative ways to lower patient costs and improve health. By utilizing enhanced care team models within the payer environment, and coupling these models with care management software, patient lives improve and costs are reduced. Healthcare costs can be used towards Sally in the event of an emergency, necessary testing and regular provider appointments instead of Sally’s frequent readmissions.

The CDC released how much chronic diseases cost and the numbers are astonishing. Healthcare costs that could be linked to obesity reached $147 billion in 2008. In 2012, diabetes diagnoses costs reached $245 billion. Because healthcare costs are always on the rise, these numbers are much higher today in 2017.

Because the cost of healthcare is skyrocketing, disease management is more important than ever. In addition, healthcare technology is the bridge to lower cost, better care, and enhanced patient satisfaction. As healthcare costs continue to rise, it is vital to discuss cost reducing mechanisms that also increase patient satisfaction and overall population health. The Triple Aim was born out of necessity, but now all parties involved see that it not only consists of attainable goals, but that is it highly effective and offers many benefits. Providers and insurers alike strive to meet the ultimate goals of the Triple Aim, not only because they feel it fiscally necessary, but also because they have seen that it truly works.

Using MedCompass® to Streamline Case Management

An image of an older couple representing the improvement of streamlining case management.

Case management may take many forms – from managing multiple transitions of care for a member to linking a member with community resources. MedCompass® allows you to assess, coordinate and plan collaboratively.

Our revolutionary technology was originally built in partnership with the Case Management Society of America.

Our unique approach facilitates proactive care management through a fully integrated database of consumer and provider information. MedCompass® coordinates all interactions using collaborative workflow management. It supports the real-time communication of information between all members of the care team, inside and outside the four walls of traditional healthcare settings.

MedCompass’s® resources include:

  • Needs assessments
  • Care planning
  • Home and community-based treatment plans
  • Third party integration
  • Alerts, triggers, notifications
  • Reporting, dashboards, analytics
  • Appeals and grievances
  • Authorization requests
  • HIPAA and MITA compliant

MedCompass® automatically generates system and user created tasks for specific activities while tracking timeliness of task completion. The system allows users to quickly review their outstanding tasks for the day, as well as flag tasks such as follow-up actions weeks in advance.

These activities can be established during implementation and added/edited/removed while in production to support the organizations current business processes.

MedCompass® is modular and highly configurable, allowing organizations to implement case management services to establish, maintain, and govern core business processes and manage case management activities.