Is Your Prior Authorization as Pain-Free as Your Patients?
What Makes Prior Auth Tougher for Pain Management Practices
Picture this:
A patient suffering from debilitating chronic pain finally gets a treatment plan from their provider—only to hit a brick wall of endless delays for payer approval after facing rejection earlier on grounds of medical necessity.
And now picture this:
The physician is left with having to choose between doing the procedure and making the patient pay for it out of pocket, or continuing to appeal the denial with the payer or lose the patient to another practice, none of which are options that serve them well.
Who would have thought that a simple cost-control measure by health plans could turn into a choke point, becoming a barrier to care and a double whammy for its key stakeholders—patients and providers?
From delaying critical treatments and exacerbating medical conditions of patients to impacting physician utilization and their reimbursements, the ripple effects of prior authorization are far-reaching and devastating, to say the least.
The urgency to fix this broken system has never been greater, and the 2023 AMA prior authorization physician survey says it all.
A Nightmare for Patients and Providers
Hindered Patient Care
When Delays Become Far Too Dangerous
Patients endure delays in necessary treatments, which can result in prolonged suffering, increased dependency on medications, and sometimes complications or even health emergencies.
Increased Physician Burnout
System on the Brink
Physicians end up spending a significant amount of time navigating payer behavior and prior authorizations—time that could otherwise be spent on patients. Besides, the constant back-and-forth over documentation adds to their frustration and burnout.
Why Pain Management Practices Struggle with Prior Authorization
Excessive and Non-Standard
Documentation Burden
(When Paper Trails Become Pain)
Providers are often boggled down by extensive, non-standard documentation requirements by payers.
An auth approval for a hip joint injection (CPT 27096) generally needs 3 provocative tests for payers like Aetna and Cigna, while others like BCBS and UHC typically do not require it.
Since most of pain management procedures require prior authorizations and there is heavy reliance on external providers for documentation with respect to imaging, referrals, and diagnostics, providers end up chasing unnecessary, protracted paperwork, which creates service delays and adds to their administrative burden, leaving them and their patients in limbo.
Clinical Necessity vs. What’s
Billable
(A Tightrope-Balancing Act)
While providers prescribe clinical necessary treatments, payers evaluate claims based on what’s payable. This creates a misalignment, especially in pain management, where repeat procedures and service limitations are common.
Payer-mandated gaps for repeat services disrupt treatment plans, while service limitations, like a cap on yearly radio frequency ablations or facet joint injections, leave providers walking a tightrope, balancing patients’ clinical needs with payers’ rigid rules.
Several payers impose limitations on the number of urine drug screens covered in a year, disregarding the fact that continual testing is fundamental to a specialty like pain management.
Longer Waiting Time and Higher
Denial Rate
(The Ticking Clock of Pain Management)
Higher turnaround times (TAT) in payer approvals and frequent denials as a result of excessive scrutiny by payers due to nature of the specialty and its use of opioid therapies result in unnecessary delays in critical, time-sensitive treatments.
One can get an approval for a trigger point injection CPT 20552 for a BCBS patient right away, whereas it may take up to 10 days to get an approval for CPT 20553, which (a) is essentially the same service and (b) depends on the number of points injected, which can't be determined beforehand.
These further impact provider utilization and their reimbursements while also adding to their burden of reworking claims.
But There’s a Remedy to the Prior Auth Pain
Fortifying Front-End Processes
Building a rulebook on payer- and service-specific requirements can help:
Understand payer behavior and ensure documentation aligns with payer needs
Optimize scheduling, keeping in account the average approval time for a service by its payer
Maintain gap between repeat services, considering patient relief, and imaging and clinical needs
Appraising and Optimizing Workflows
Taking a critical look at prior authorization workflows can help:
Pinpoint inefficiencies resulting in delays–submission or payer approvals–to reduce errors and unnecessary rework
Ensure regular root cause analysis (RCA) of auth and claim denials and establish a feedback loop to prevent recurring denials
Plug revenue leaks and eliminate bottlenecks impacting the cash flow
Tracking and
Governance
Following a KPI-focused approach and establishing a governance system can help:
Monitor key metrics like the auth approval rate and denial rate to identify areas requiring immediate action
Identify trends in payer behavior and industry regulations and adapt to shifts
Use technology and expertise in the best way possible to fine-tune processes for continuous improvements
How Jindal Healthcare Simplifies Prior Authorization for Providers
At Jindal Healthcare, we empower pain management practices to tackle prior authorization head-on by leveraging our tech-enabled expertise for workflow optimization.
By ensuring accurate documentation at every step of the way, we pave the way for seamless patient access and improved financial outcomes for the practices, while allowing them to stay fully committed to patient care.
SOP-Driven Documentation Precision
Experts on payer watch, constantly updating payer-specific client SOPs for accurate, compliant documentation, enabling faster approvals, fewer denials, and seamless patient access
Denial Defense Done Right with RCA and Feedback
Tech-enabled experts performing RCA on auth-and claim-related denials and preventing rejections with a robust feedback loop—ensuring things keep moving like a clockwork
KPI-Focused Revenue Cycle Governance
Power BI intelligent dashboards offering actionable insights into prior authorization workflows and critical KPIs, enabling informed decision-making for continuous process improvements
SOP-Driven Documentation Precision
Experts on payer watch, constantly updating payer-specific client SOPs for accurate, compliant documentation, enabling faster approvals, fewer denials, and seamless patient access
Denial Defense Done Right with RCA and Feedback
Tech-enabled experts performing RCA on auth-and claim-related denials and preventing rejections with a robust feedback loop—ensuring things keep moving like a clockwork
KPI-Focused Revenue Cycle Governance
Power BI intelligent dashboards offering actionable insights into prior authorization workflows and critical KPIs, enabling informed decision-making for continuous process improvements
What Sets Us Apart
35%
Increase in
Average Revenue
92%
Authorization
Approval Rate
50%
Reduction in
RCM Costs
Simplify Prior Authorization with Jindal Healthcare for Seamless Patient Access
Partner with Jindal Healthcare and let our experts help you build robust prior authorization workflows to pave the way for seamless patient access and improved care and financial outcomes.
