Common Challenges in Hospital Prior Authorization and How to Handle Them

Getting face to face with Hospital Prior Authorization

In the realm of medical billing, Prior Authorization remains one of the most hotly debated ones. And when it comes to a large healthcare facility, such as a hospital, prior authorization assumes a position of particular importance. Physicians are often found complaining about how the process causes delays in initiating care, leading to poor outcome and even abandonment of treatment. Typically speaking, hospital prior authorization requests are made in high volumes. Every year, the number of drugs and services that require prior authorization is increasing, along with new payers and health plans emerging in the market. This is making matters even more complicated for hospitals and other healthcare organizations. There are fresh norms to be followed, newer PA request forms to be filled, newer protocols to be complied to.

Besides this, prior authorization still continues to be done using traditional methods, such as collecting and faxing paper-based documentation to the payer’s office, making phone calls to the insurance representative’s desk, manually following up on denials and so on. Even with the growing acceptance of e-authorization standards across the healthcare space, many providers and payers continue to conduct matters the old-fashioned way. The flip side of this approach is the inordinate amount of time it takes, on an average, to complete a single request. In cases where the volume is high and the number of regular staff members falls short to handle all the requests efficiently, nurses and other medical staff are brought in to manage the extra rush. This naturally takes a severe toll on providing actual care as important hospital staff members become unavailable to attend to patients.

Measures for taking the load off

The natural solution to this problem seems to lie in employing more personnel to handle the extra burden of hospital prior authorization requests. However, in reality, finding such personnel is not an easy task, especially during these times of labor shortage. There is an acute shortage of skilled billers and revenue cycle management personnel in the market today. Even if one were to find them, employing them as regular hospital staff can quickly cause the operational expenses to rise.

In the face of such issues, healthcare providers are increasingly engaging external assistance on contractual basis. Highly skilled and fully-trained Prior Authorization experts working dedicatedly on a low hourly rate of compensation, is becoming an increasingly common sight across the healthcare sector in the U.S. The advantages of such an arrangement are many. For one, it allows hospitals to gain instant access to a ready pool of billing and coding professionals without having to go through the usual rigmarole of finding, training and recruiting them. It also allows for huge cost savings as there is no overhead cost or employee benefits to be provided. Providers are required to pay only for the actual hours of work done.

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