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How are Medicare outpatient procedures complicated by PA requirements?

Navigating the healthcare system can feel like walking through a maze and for providers working with Medicare outpatient procedures, prior authorization (PA) is often the most frustrating dead end. It’s supposed to prevent unnecessary care and save money. In reality? It frequently causes delays, denials, and massive administrative headaches, especially in Medicare Advantage.

This article breaks down exactly how PA complicates care, what the process involves, and why leveraging Staffingly’s virtual staffing model may be one of the smartest ways to streamline approvals and keep patients on track.

What Is Prior Authorization?

Prior Authorization (PA) is a requirement from insurance plans that providers must get approval before performing certain procedures or prescribing certain medications. It’s designed to ensure services are medically necessary but it often ends up being a bottleneck that slows everything down.

The PA Process Step-by-Step:

1. Provider recommends a treatment or procedure (e.g., MRI, physical therapy, outpatient surgery).

2. Staff submits a PA request to the insurer (Medicare Advantage plan, in this case), including documentation like clinical notes, diagnostic results, and justification.

3. The insurer reviews the request, sometimes requiring additional information or applying their own internal guidelines (which may differ from Medicare’s).

4. Decision is issued approval, denial, or partial approval. If denied, providers may appeal.

5. If appealed, further rounds of documentation, peer-to-peer reviews, and resubmission are involved potentially delaying care by days or even weeks.

How PA Complicates Medicare Outpatient Procedures?

For providers serving Medicare Advantage patients, PA is no small hurdle:

• Volume overload: Nearly 50 million PA requests were processed in MA plans in 2023. That’s about 1.8 requests per enrollee per year.

• Denials are common: 6.4% of PA requests were denied in 2023 that’s 3.2 million services blocked or delayed, even though over 80% of appeals eventually succeed.

• Delays in care: 94% of physicians say PA causes delays. In specialties like oncology and rehab, delays of 5–12+ days are common.

• Patient harm: Up to 24% of physicians report seeing serious adverse events (including hospitalizations and deaths) caused by PA-related delays.

• High-burden services: Imaging (e.g., MRI), physical therapy, outpatient surgeries, DME (like wheelchairs), and injectable medications are frequently tied up in PA.

And don’t forget the cost of all this red tape: Providers spend over $25 billion annually on administrative PA work. Many are hiring full-time staff just to manage prior auth workflows.

How Staffingly Helps Providers Tackle Prior Authorization?

That’s where Staffingly steps in.

Staffingly is a healthcare workforce solution that provides trained virtual medical assistants (VMAs) and administrative support to practices overwhelmed by the day-to-day chaos of billing, scheduling, and yes – prior authorization.

Here’s How Staffingly Simplifies the Prior Authorization Process:

  1. Dedicated Prior Authorization Support

Staffingly assigns specialized virtual team members who are fully trained in:

• PA submission workflows

• Documentation best practices

• Insurer portals (e.g., Availity, NaviNet, UHC portals)

• Appeals and peer-to-peer scheduling

They handle the PA process from end to end, reducing staff burden and freeing up clinical teams to focus on patients.

  2. Faster Turnaround, Fewer Delays

Staffingly’s assistants are trained to get it right the first time  submitting clean, complete, and timely requests to avoid denials or documentation rejections.

This minimizes delays and helps keep patients on schedule for time-sensitive services like imaging, infusions, and surgeries.

  3. Appeal Management

If a request is denied, Staffingly’s team will:

• Track the denial reason

• Gather necessary documentation for appeal

• Coordinate provider sign-off

• Submit and follow through until resolution

With 81.7% of Medicare Advantage denials overturned on appeal, having a reliable system for appeals is critical and Staffingly helps you capitalize on that opportunity.

  4. Integration With Your EHR and Workflow

Staffingly doesn’t operate in a vacuum. Their VMAs:

• Work inside your existing EHR system (Athena, eClinicalWorks, etc.)

• Communicate with your in-house team via secure channels

• Are assigned exclusively to your practice – they learn your preferences, your patients, and your providers

This consistency means fewer handoffs, less confusion, and faster results.

  5. Cost-Effective Scaling

Rather than hiring another full-time staff member (with salary, benefits, and training costs), practices can scale their team with Staffingly VMAs at a fraction of the cost. It’s ideal for small and mid-sized practices juggling heavy MA volumes without overwhelming their in-house staff.

Benefits of Using Staffingly for Prior Authorization