The COVID-19 pandemic has put enormous stress on healthcare providers, forcing them to adapt their processes and workflows quickly. One of the challenges that healthcare providers have faced during the pandemic is insurance authorization for imaging and radiology services, which has become a bottleneck, leading to delays in patient care. To address this challenge, the Atlantic Health System undertook a project to streamline the insurance authorization process. This article details how the Atlantic Health System streamlined insurance authorization to improve the patient experience and reduce costs.
Healthcare Providers During COVID-19 Pandemic
The COVID-19 pandemic has had a significant impact on healthcare providers. The rapid spread of the virus and the high number of patients requiring hospitalization placed unprecedented demands on healthcare systems. Healthcare providers had to quickly adjust their workflows and processes to accommodate the high volume of patients, adhere to safety guidelines, and provide quality care. One of the challenges that healthcare providers faced during the pandemic was delays in insurance authorization for imaging and radiology services, often leading to delays in patient care.
Insurance Authorization as a Bottleneck
Insurance authorization is a critical but often complex and time-consuming process that requires coordination between healthcare providers, insurance payers, and patients. Delays in insurance authorization, often due to missing information or documentation, can cause appointment cancellations and rescheduling, leading to longer wait times and increased expenses for both patients and healthcare providers. This was particularly evident during the COVID-19 pandemic, where authorization delays for imaging and radiology services had a significant impact on patient care.
Streamlining the Insurance Authorization Process
To address the challenge of insurance authorization delays, Atlantic Health System undertook a project to streamline the process. The project aimed to improve the patient experience by reducing waiting times, minimizing the potential for appointment cancellations, and reducing costs associated with denials. The project also aimed to increase staff satisfaction by providing them with a streamlined and efficient process.
Intelligent Rule-based Analysis for Identification of Required Authorizations
The project utilized intelligent rule-based analysis to identify the required authorizations, which allowed for more effective and efficient authorization workflows. The system analyzed patient information, insurance information, and other relevant factors to determine the appropriate authorization for each appointment. This approach eliminated the need for staff to manually verify insurance coverage and requirements, reducing the possibility of errors and delays.
Automation of Polling Payer Portals for Updates
The project also utilized automation to poll payer portals for updates on authorizations. This approach allowed staff to receive real-time updates on authorizations, reducing the potential for cancellations due to denied or delayed authorizations. The system also automatically identified authorizations that had been updated, allowing healthcare providers to reschedule appointments quickly and efficiently.
To implement the new prior authorization workflows, Atlantic Health System tested the standardized process with small group sessions involving key stakeholders, such as providers, revenue cycle staff, and payor representatives. The sessions allowed stakeholders to collaborate, identify potential issues, and develop solutions to address them. The testing phase allowed the team to refine the prior authorization workflows and ensure they met the needs of all relevant stakeholders.
Reduction in Denied or Delayed Authorizations
Less than 1% of appointments are now cancelled due to denied or delayed authorizations which is a significant improvement from the pre-streamlining period. This improvement can be attributed to the use of intelligent rule-based analysis and automation, which reduced the potential for errors and delays.
The project has significantly reduced the time it takes to submit authorizations by more than 50%, which is 50% below the industry average. The streamlined process and the use of automation have allowed staff to focus on higher-value tasks.
Extending automation to other service lines
Building on the success of the project to streamline insurance authorization for imaging and radiology services, Atlantic Health is now considering extending automation to their other service lines, such as surgery and cardiology. This approach can provide additional benefits for patients, healthcare providers, and payers, reducing wait times, improving patient experience, and lowering costs.
Success attributed to focusing on the business problem
The success of the project can be attributed to Atlantic Health System’s focus on the business problem, rather than the technology. While the technology played a critical role, the team prioritized understanding the root cause of the problem, developing a solution that met the needs of all stakeholders, and testing and refining the solution for optimal performance.
Importance of Keeping an Open Mind and Willingness to Fail Fast, Learn, and Adapt
Finally, the success of the project highlights the importance of keeping an open mind, being willing to take risks and fail fast, learn, and adapt. By continually refining the prior authorization workflows based on stakeholder feedback, Atlantic Health System was able to deliver a solution that met the needs of everyone involved.
The conclusion states that during the COVID-19 pandemic, streamlining insurance authorization for imaging and radiology services posed a significant challenge for healthcare providers. However, Atlantic Health System was successful in addressing this challenge by using intelligent rule-based analysis and automation, which improved the patient experience and reduced costs. By keeping an open mind, focusing on the business problem, and adapting to stakeholder feedback, Atlantic Health System was able to develop a solution that could be extended across other service lines, providing benefits to patients, healthcare providers, and payors.