Why Chief Medical Officers Must Take a Lead Role in Fixing Prior Authorization

Posted by Pat Morrell on Jan 4, 2019 12:10:00 PM

You’re a Chief Medical Officer. You’re busy. Too busy to read long blog posts. So this one is short / sweet / direct.

This year, you as the CMO can—and must—be the one to help fix prior authorizations.

And you can do it quickly, cost-effectively, and easily with the help of A.I.

But more on that latter. First, I want to address what I’d expect are your impulse reactions:

“We’re not short on problems at my [practice, hospital, clinic]… is this a problem that needs solving?”

Prior auth is one of the foundational areas of the revenue cycle that hampers providers’ financial health. To put the cost impact in a staff context, prior auth administration consumes 20 hours a week per clinician and costs an average of $83,000 a year per doctor.

“OK, but why is it my problem to solve?

Great question. You’re the senior-most leader accountable for patient treatment outcomes and physician retention. Prior auth threatens both.

Yes, your CFO counterpart owns the revenue cycle. And yes, prior auth is part of the rev cycle. But prior auth is not just creating a financial burden. Prior auth is creating a patient treatment experience crisis. Recent studies and surveys by the AMA make this clear:

  • Over 80% of docs report an increase in auth burden, “repeat auths”
  • 92% of docs say prior auths negatively impact treatment
  • 78% report patients may stop treatment due to auths issues

Worst yet, the crisis is growing: prior authorizations have risen 54% in volume in the past 4 years.

And processes like prior auth contribute to clinician burnout, which negatively impacts treatment outcomes.

Per a recent study in Mayo Clinic Proceedings, Dr. Daniel Tawfik, MD, MS, asserts: “A multifaceted approach [to mitigating medical error] that also addresses physician burnout is needed. The most effective burnout reduction will require system-level changes to reduce unnecessary documentation and clerical burden, promote efficient use of physicians’ time.

Another recent study from the Cleveland Clinic showed upwards of ⅓ of their physicians suffered from burn-out (also attributable in part to admin tasks), and that “[These] findings have important implications for physician retention and healthcare delivery” (Amy Windover, PhD).

As the Chief “Remover of Care Delivery Impediments” and “Retainer of All-star Docs and Nurses”, these statistics and studies put the prior auth ball in your court.

“... So... then... how should I solve this?

Let’s start with what you likely can’t do:

  1. Convince your CEO or CFO counterpart to add more FTEs to the revenue cycle team (this is triage anyway—it won’t solve the underlying issues plaguing prior auth).
  2. Add more support staff of your own (like many CMOs, you’re likely facing budget constraints and headcount caps… and, again… triage).
  3. Negotiate your way out of prior auths with payers (or even change the dynamic rules they employ)
  4. Get your CIO counterpart to find a solution from your EHR provider
  5. It would take too long to implement (you can’t afford another 18-month installation)
  6. EHR providers are white-labeling solutions like ours anyway (another blog post for another day)
  7. What you need is basic. It’s an outcome. You need faster treatment authorizations, delivered at less cost, and with fewer denials. You need a technology solution.
  8. Lia, our system of intelligence for smarter and faster prior authorizations, is the best on the market to deliver that outcome. You can see her in action here.

“I didn’t read this blog to get a sales pitch…”

Bingo. You’re here because you need advice and help. So here it is: whether you go with us/Lia or not, here are the things you should look for in an A.I. solution for prior auth that can help you make the right decision.

Performance and Technical Criteria:

  • Does it work 24/7, behind-the-scenes, with no disruption to your admin support staff and clinical team (no new training or workflow tools)?

  • Does it operate in “real-time” at the pace of your clinicians? (If you hear “batch uploads”—run!)

  • Does the solution get up and running fast (i.e. 60-90 days, at most)?

  • Does it focus on prior auth, or is it an “all-things-RCM” solution? (An all-in-one sounds attractive, but there is considerable risk in working with vendors who try to boil the ocean.

  • Does it actually integrate with your existing EHR (no automation bots, but API integrations)?
  • Does the solution (and company) have a track record for delivering ROI? (Lia does…)

  • Can it use machine learning to anticipate payer behavior (predict the likelihood of authorization/denial likelihood, predict the timetable for auth, etc)

  • Was it built from the ground-up with A.I., and incorporate a cognitive feedback loop that allows it to get smarter (and more valuable) over time)?

    Learn more about Lia here

Non-Technical Criteria

But just as important as the technical and performance attributes, you need an A.I. partner that delivers the needed outcome and believes in your same values.

A partner that strives to help health care workers deliver the right care, to the right patients, at the right time. A partner with a team comprised of not only tech and A.I. veterans, but daughters of hospital nurses, brothers of physicians, and sons of CMOs.

We understand the burden your teams and patients face and have made it our mission to partner with CMOs like you in order to solve this crisis plaguing our health care system. And we pursue this mission with our company values of Trust, Transparency, and Courage, at our foundation (you can read more about them here, and see them in action in our other blog posts here).

Regardless if you choose us, or our system Lia, to help fix your prior authorization problems, we hope that you do engage with a team that shares the same ethics and values around A.I. technology and a passion around this subject in particular.

Pat Morrell

Written by Pat Morrell

Topics: AI, Prior authorization, Intelligent automation, Artificial intelligence, Pre-authorization, Revenue cycle management, Healthcare IT, Healthcare, Pre-certification, Revenue cycle, System of intelligence