Healthcare organizations can reduce their administrative burden and increase their bottom line by outsourcing prior authorizations. However, to achieve these benefits, outsourcing must be done correctly. Most healthcare organizations implement prior authorization outsourcing without thoughtful consideration, which leads to delays, denials, and increased non-compliance risk. Providers will have success outsourcing prior authorization services if they adequately plan for the process.
1. Assess Your Internal Workflows
Before outsourcing prior authorizations, assess your current healthcare prior authorization processes. Identify the gaps, pain points, areas where documentation is missing and gaps pertaining to specific insurance carriers. Without an understanding of your prior authorization process, outsourcing will result in yet another team that is struggling to process authorizations.
Understand how requests are started, how clinical documentation is collected, and how submissions to the payer are tracked. Internal processes guide the selection of the right prior authorization partner aligned to your volume.
2. Identify the Ideal Partner
The prior authorization outsourcing industry is like any other industry—some are good and some are not. One of the largest pitfalls of practices is selecting providers based on their fees. Options for consideration should include experience, knowledge of the specialty, quality and timeliness of turnaround, and compliance.
Consider the following questions when evaluating prior authorization companies:
Do they cover prior authorization for surgical and other complicated procedures?
Do they understand payer-specific guidelines for prior authorization?
Do they provide complete prior authorization services?
What KPIs (Key Performance Indicators) do they monitor? (e.g. approval rates, turnaround times, denial rates)
A reputable partner should show and understand the intricacies of medical prior authorization and provide assessable deliverables.
3. Assess Technology Compatibility
A common error in outsourcing is technology gaps. If the vendor’s medical prior authorization software does not integrate with your EHR or billing system, the pre authorization in medical billing and claim submission will be disrupted.
Select a partner whose medical prior authorization software is compatible or can integrate with your systems for efficient operation. This is because integration promotes real-time updates, accurate documentation transfer, and smoother claim submission.
4. Establish a Clear Communication Framework
Missing documents and denied requests are the results of poor communication. Set communication protocols when outsourcing prior authorization services so that escalation and reporting are structured.
Establish timeframes for:
Daily or weekly updates
Handling of urgent requests (especially prior authorization for surgical procedures)
Turnaround times
Document requirements
Effective communication enhances the synergy of both teams within the healthcare prior authorization process flow.
5. Compliance and Data Security
There are also pieces of patient information involved in prior authorizations. If you are outsourcing prior authorizations, make sure that the partner is HIPAA-compliant and has secure data transfer methods. If not, the partner will have legal and reputational risks.
A prior authorization outsourcing partner that is reputable will also have formal policies related to security, secure communication methods that are encrypted, and will undergo compliance audits as a part of the partnership.
6. Use Metrics to Measure the Success of the Partnership
When outsourcing prior authorizations, you also need to measure the results. Make sure you are measuring the following:
First Pass Approval Rate
Authorization Turnaround Time
Denial Rate
Success Rate of Appeals
The best prior authorization solutions have dashboards with these metrics built in as well as periodic reports. To ensure that your prior authorizations for insurance are done accurately and in a timely manner, you need to monitor these metrics.
7. Staff training
Prior authorization also requires that the internal staff are trained on the documentation needed and the rules of the payers. Clinical teams need to be trained to ensure that complete and correct information is provided in order to avoid delays in the authorization of the medical services.
Training will enhance the workflow of the staff and the outsourced specialists, improving the overall medical billing workflow of the prior authorizations.
8. Beginning with a Pilot Program
Instead of outsourcing every service, try doing it in phases. Start with high-volume services or particular specialties. This gives you the ability to assess a vendor's competency in managing end-to-end prior authorizations services before extending the relationship.
Final Thoughts
Sticking to a plan, good technology, clear communication, and constant follow-up can help you minimize the errors that come with prior authorization outsourcing. Care providers can decrease approval times and increase revenue cycle efficiencies by choosing prior authorization companies that have good systems integration and monitoring metrics.
With a good plan, outsourcing prior authorization services can help turn a tedious administrative process into a streamlined and revenue-generating process.
