Addressing problems associated with prior authorizations [PODCAST]

Mike Passanante: Hi. This is Mike Passanante, and welcome back to the award-winning Hospital Finance Podcast. Delays in prior authorizations for medical services can impact patient care and health. To talk with us about current issues related to prior authorizations and what the healthcare industry is doing to address them, I’m joined by Joe Anstine, CEO of PriorAuthNow, an Ohio-based corporation that provides a SaaS-based platform to submit, monitor, and complete prior authorizations for all patient care. Joe, welcome to the show.

Joe Anstine: Thanks for having me, excited to be here.

Mike: Joe, most people in our audience are probably at least somewhat familiar with prior authorizations, but just to get us started, can you briefly explain what prior authorizations are and how providers are expected to handle them?

Joe: Yeah, of course. So what folks may or may not know is anytime a patient goes to the doctor and the doctor decides to perform some type of care, and that care could be anything from prescribing an expensive drug, it could be to doing a diagnostic test, or something far more invasive like a surgery, what that doctor has to do prior to being able to deliver that care to the patient is actually reach out to the insurance company to get approval for that particular care. And that process of getting that approval, it’s called a prior authorization. Today, that prior authorization process is very manual process that oftentimes results in a back office person having to go through a number of different steps to actually get that decision from the insurance company. So at a high level, that’s what an authorization is. And again, oftentimes it falls back to some of that back office staff to actually complete.

Mike: Yeah, let’s unpack that a little bit. So can you elaborate on the problems that healthcare providers are facing with prior authorizations in the current environment?

Joe: Yeah, absolutely. In fact, if any of your listeners are wondering, I challenge them to go ask a provider what are their sort of top challenges. And pretty much, every time we have done that, prior authorization pop up in at least the top two, if not number one, and a lot of that is around the fact that the prior authorization process is incredibly manual. What I mean by that is the process to do it uses archaic processes and technology. For example, most of the prior authorizations are done via phone call and a fax machine. The other sort of contributing part to this manual process is the fact that every single health insurance company has their own payer portal where you can go and actually enter in information manually to their portal and wait for a response to come back. The problem with that process is every single health insurance company has its own portal. I sort of equate it to if you go to the grocery store and you buy your milk and your dairy and everything else you have, when you go to checkout, you have to check out over here with your dairy, you have to check out your snacks in this aisle, then you have to check out your meats over here, right? Eventually, you’re going to say, “This is silly. Why am I checking out in so many different places,” right? And that’s similar to how folks feel around the prior authorization process, so it’s incredibly manual and it’s time-consuming. And there’s really two parts to it – right? – there’s the, “Hey, an order has hit my desk and now I need to know, does it even require an authorization?” Right? Most of the time, providers are unsure if it requires an authorization. Once they figure out if it’s actually required, then they have to try and figure out, “Where do I actually submit this thing?” And for those of you who have tried to unpack patient plans and actual coverage information, it’s incredibly difficult sometimes to figure out who actually manages this benefit, right? So there’s a lot of manual process before you can get to the hard part, which is the prior authorization itself, which is once you actually submit the information, which all of that is done manually, either manually entering in each piece of information into a payer portal or actually having a pen and paper and writing it on a faxed form and then faxing that out or waiting on hold for 45 minutes to an hour trying to get a live person on the other end to enter that information so that the prior authorization is “submitted.”

And then once it’s actually submitted, having to do the hurry up and wait game of waiting for the insurance company to come back and actually tell you a decision. And that’s if they don’t ask for more information or ask for a peer-to-peer or some other sort of invasive process to try and get an approval. So as you can tell, very, very cumbersome process, not just delivering the authorization, but the things that also surround it.

Mike: Yeah, and as you’ve intimated, providers and payers come at this issue from opposite sides. They each have things they’re trying to get done in the process and maybe they’re trying to do that in the best way they think that they can, but Joe, what do you think can be done to get them working together on the problem?

Joe: Yeah, so it’s a great question. And for far too long both of these, the major constituents within this process, providers and payers, have tried to solve it sort of in their own vacuums and I think that’s a lot of the reason why there’s no real solution out there today. And one of the things that we believe very strongly is that when this is done right, everybody wins. If you look at from a payer perspective to start, the prior authorization is one of the most expensive transactions that they manage at over $35 per transaction. That’s a large amount of money knowing that– I think UHC just posted they do upwards of 60 million a year, maybe even higher than that, an enormous amount of transactions and the cost associated is so high because of the manual nature in which the payer has to review these things. One of the problems is that– one of the reasons why the payers can’t automate it is that providers are submitting it manually, right? And one of the reasons providers are submitting it manually is because payers don’t have a process to submit it electronically or if they do it is such a cumbersome process to get it to them that way that providers just don’t actually use it. So one of the things that we talk a lot about is being able to apply different standards. There is no such thing as a single way that folks or payers need to accept an electronic transaction, right? There should be ways in which to sort of automate any way they can accept it electronically, right? So whether it’s FHIR or whether it’s HL7, whether it’s API or whether it’s an EDI transaction, it does not matter. If the payers has the ability to receive it electronically, there should be something out there that delivers it to them in that electronic way and sort of meets them where they’re at, that’s how you get rapid change. It’s not trying to make payers sort of accept a brand new way of doing things that has a very long tail, it’s meeting them where they’re at and being able to support whatever way or whatever standard they’re leveraging to submit a prior authorization electronically.

We should be able to conform to how they do that. The second part of that is we also should take that same methodology to the provider side. We should not force a provider to change their workflow in order to adopt a certain standard, right? One of the things that has to be done is being able to take the way in which payers can receive data electronically and be able to integrate that into a provider’s existing workflow, whether that’s integrating into one of their existing queues, right? So people that process prior authorization on the provider side will often have queues where patients are filling up in these queues and they just work down that queue – right? – not asking them to replace their existing queue or use two queues now, right? You have to be able to integrate how and which the payers want to receive the data in a way in which the providers are already using. So it’s a big, big deal to be able to take the technology and be able to integrate it in a way that is not disruptive to the provider’s workflow. And then finally, what I think both constituents need to remember is that the number one constituent base that is affected by the prior authorization is the patient, right? And if payers and providers are serious, and I believe that they are, and that in fact, when they say, “There’s nothing more important than the patient,” then that should be motivation alone to be able to work with the right people out there that can actually solve this problem for good because remember, when this thing is done right, literally everybody wins.

Mike: And Joe, I do want to drive into the providers a little bit more. I’m sure in your experience you’ve seen them try to handle this rather manual process in a number of different ways. I’m wondering if you can describe what some of those attempts look like?

Joe: Yeah, absolutely. Right now, largely, they throw people at this, right? So they have floors and floors of people who do nothing but submit authorizations. And right now, the way in which that they’re trying to attack it is they’re trying to automate sort of existing entry points or trying to automate ways in which the payer’s already received that data. And the problem with that is is they’re trying to automate an already bad process, right? There’s not much value that can be derived from automating a process that’s just flat out broken right now, right? So whether it’s throwing people at it or whether it’s trying to apply a piece of technology to automate a payer portal or to automate a fax, those are archaic ways of communicating with a payer. And just by automating those you’d limit your upside, right? What has to be done is sort of create a net new way of being able to exchange data in a much more seamless way and I think as you sort of dig into where providers are trying to solve this, they have nowhere else to turn, right? There’s not a lot of folks out there who are actually working with the payers to actually provide net new ways of connecting with them or supporting their existing standards. So I don’t blame the providers, right? They have to make do with what they have, which often right now is, again, throwing people at it or trying to automate an already manual process, which you get some lift from that. I think there’s some efficiencies to be gained, but it nowhere near sort of removes– or solves the larger problem we’re dealing with here, which is this is a manual process on both sides that takes a very long time and that it still impedes patient care. So the way in which they’re currently doing it, they’re sort of doing out of desperation or pure survival but it’s not actually getting at the core problem which is the UM motion is an important part of the US healthcare ecosystem, it just shouldn’t be carried out the way it is today because the way in which it’s carried out, even when providers try and automate as much as they can of it, still ultimately ends up impeding patient care, having folks schedule things 7 to 10 days out, and, ultimately, not being able to deliver the right care at the right time for the patient.

Mike: Yeah, so it’s an extremely inefficient process. Joe, I’m curious if you can tell us about what you think are some of the must-haves that need to be in place to drive greater efficiencies?

Joe: Yeah, I think the one that people often overlook, and it sort of dovetails what I just mentioned, which is providers can’t solve this alone, they have to have the payer playing ball on the other side. So in order to solve this correctly, they have to be in a position where the payer is actually incorporated in the workflow in a way that allows them to transfer data more seamlessly. So trying to automate an existing payer portal is not getting the payer involved, right? It’s a difficult problem. It’s a different way to try and solve the problem and you have limited upside, right? So you have to have the payer at the table in order to solve this correctly. The second piece is we cannot ask providers and payers to change all of their existing workflow in order to solve just this problem. That’s going to take far too long, far too much money, and this is a problem that needs solve now, not 10 years from now. So we’ve got to be in a position where we get the payer to the table, we provide a way that we can improve the way in which they exchange data on both sides so that it’s not disruptive to their overall workflow, and then finally, it’s not just about turning it into an electronic transaction, we have to automate that transaction. So a lot of people talk about electronic prior authorization and while that is a good thing, we sort of see that as an anti to play. What you really need is to be able to automate the process, right? Eventually, this process will be one that is completely run in the background, right? This shouldn’t be a decision state, right? This should be a surveillance state where if you have the correct connectivity on the provider and the payer side, we should just be able to just surveillance on the data that’s being entered in about that particular patient and be able to run these UM checks and prior authorization checks automatically, not having people have to manually enter information and spend time on administrative tasks when their time could be focused in on actually improving patient care and interacting with the patient which is, quite frankly, why most people got into healthcare to start with.

So at a high level, those are some of the most important parts. And again, just to quickly rehash, it’s getting the payer to the table, right? It’s about meeting the provider and the payers where they’re at and incorporating into their existing workflows, those are incredibly important. And it’s not just about creating an electronic transaction, it’s about creating an electronic transaction that can be more automated. It has the same UM result, but it does it in a way that doesn’t drive up cost and take time away from interacting with patients.

Mike: Great insights. Joe, if someone wanted to learn more about your company and what you do, where can they go?

Joe: Yeah, so we spend all of our time here at PriorAuthNow thinking about these problems and figuring out how to solve them so that everybody wins. So for more information, please feel free to visit our website which is www.priorauthnow.com. Again, that’s prior, P-R-I-O-R, auth, A-U-T-H, now, N-O-W, dot com.

Mike: Joe Anstine, thanks so much for joining us today on the Hospital Finance podcast.

Joe: Thank you. It’s been a pleasure and I appreciate the time today.

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