Deemed one of the most critical frontline functions of revenue cycle management (RCM), prior authorization continues to play a pivotal role in not only setting the stage for a stable cash flow for a practice but also shaping the experience patients have with that practice. Despite its indispensability and criticality in confirming the coverage and medical necessity for clinical procedures, prior authorization has historically been a source of frustration for both providers and patients. This is because delays and denials in pre-authorization result in not only underutilized clinical staff and an impacted bottom line but also cause a huge setback to smooth patient access to care.

The Far-Reaching Effects of Inefficient Prior Authorization

For many providers, pre-authorization continues to be a painstaking task owing to the overwhelming burden it puts on them to keep up with shifting payer requirements. Not only it takes away their valuable time from patient care but also becomes a barrier to timely care delivery if approvals are not obtained in time, resulting in disgruntled patients. Additionally, inconsistent payer criteria and documentation errors lead to delays, rejections, and, sometimes, costly denials.

The struggle these providers face with tedious pre-authorization processes has been underscored in the 2023 AMA Prior Authorization Physician Survey by the American Medical Association (AMA), highlighting

Over 94% physicians reporting care delays
Over 95% reporting physician burnout
Nearly 1 in 4 reporting adverse healthcare events for patients
More than 25% reporting payer denials despite putting 12 hours a week

The repercussions of delayed or denied prior authorization can be felt across all levels. From physician burnout and low employee productivity to poor patient outcomes, and even unnecessary hospitalizations, the implications of inefficient prior authorization send a clear message to providers that they need to address this pain point now.

AI: A Beacon of Hope amid Payer Delays and Denials

Providers bearing the brunt of payer delays and denials need to strategically approach prior authorization to create seamless patient access. They need to unabashedly embrace artificial intelligence (AI) to create a streamlined front-end ecosystem that fosters efficient provider-patient-payer collaboration and supports documentation that complies with payer needs for prompt approvals, timely care delivery, and enhanced bottom line.

AI adoption, in recent years, has grown manifold in healthcare, with about 46% health systems now useing AI in their RCM, especially at the front-end, where operational inefficiencies can contribute significantly to denials at the back-end.

AI’s incredible ability to optimize workflows, automate processes, and facilitate actionable insights for process improvements is now being leveraged by providers to address their prolonged prior authorization challenges.

Here are the five effective ways in which AI can help your practice beat prior authorization woes and master patient access:

Breaks Down Siloes to Boost Collaboration: By deploying AI into your RCM workflows, you can eliminate data siloes, creating a more transparent framework for all stakeholders to access and exchange essential patient information. This seamless exchange of department needs helps in ensuring clinical documentation in accordance with payer needs, better collaboration across the board, and minimal scope of miscommunication that might cause any delays in obtaining prior authorizations.
Streamlines Workflows for Better Outcomes: Integrating AI into existing workflows and EHRs can help automate repetitive tasks, freeing clinical staff of unnecessary administrative hassles, and create a more efficient system to identify gaps in clinical documentation. By parsing massive amounts of data sets in real-time and understanding payer requirements for documentation, AI helps ensure complete, accurate documentation reaches the payer for approval, thus paving the way for timely care, better patient outcomes, and improved flow of revenue into the practice.
Predicts Denials to Mitigate Risks: AI leverages machine learning (ML) to predict the likelihood of approval or rejection based upon the historical documentation submitted to the insurer by the provider. By leveraging predictive analytics, AI can help foresee potential denials and delays, allowing you to take proactive actions to ensure documentation in compliance with payer needs before submission, thus mitigating the risks for denials and enhancing the turnaround for timely patient care.
Monitors KPIs to Optimize Revenue: AI-powered workflows can help you measure, track, and comprehend the financial performance of your practice using intelligent dashboards powered by business intelligence (BI) in a simplified way. By measuring your prior authorization metrics like the pre-authorization rate, the reschedule rate, and and the denial rate, you can identify the areas requiring improvements and take necessary measures to bridge the gaps that can potentially result in prior authorization delays or denials.
Reduces Delays in Care and Reimbursements: Efficient AI-powered prior authorization solution is key to improving access to care, health outcomes, and bottom line. Leveraging the technology to streamline pre-auth tasks while ensuring human intervention when needed can help in securing prompt approvals, thus reducing the patient wait time and the underutilization of clinical staff, minimizing administrative burden and overhead costs, and improving the cash flow for your practice.

Learn how Pain Management Group Revenue Leaps by 30% with Streamlined Claims Filing.

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AI and RCM: The Partnership You Need to Transform Your Pre-Auth Process

Given the shifting payer criteria and needs, providers embracing the synergy of AI and RCM to boost the efficiency of their prior authorization workflows are expected to reap benefits from it. They will not only reduce their overhead costs and staff burnout but will also gain from timely payer approvals to better their patient and financial outcomes.

However, to fully capture the value of AI-enabled RCM and bridge the gap between revenue integrity and prior authorization, health systems need to ensure their existing tech stack supports AI, there is complete buy-in from all stakeholders, and their staff is trained to optimally use AI. They need to be mindful of the fact that they can achieve financial sustainability using AI only if they meet the requisites for the technology to function at its best.

For those finding AI integration a challenge should seek expert support from an RCM consultant. An AI-powered prior authorization solution from an RCM service provider can help them achieve simplified and faster pre-authorization workflows to secure prompt payer approvals for an elevated bottom line and enhanced patient experience.