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What Are Common Challenges in Prior Authorization, and How Can You Overcome Them?

Prior authorization is a critical process in the U.S. healthcare system, ensuring that prescribed services, procedures, or medications meet specific insurance requirements before approval. However, this process can be challenging for providers, often delaying patient care and creating administrative burdens. From navigating complex payer-specific requirements to gathering accurate documentation, prior authorization demands meticulous attention to detail. Without proper handling, errors or delays can jeopardize care timelines and increase operational costs. Understanding and overcoming these common challenges in prior authorization is essential for healthcare providers aiming to deliver timely and effective care.

Thankfully, with the right strategies and tools, many of these hurdles can be addressed effectively. Streamlining workflows, leveraging technology, and outsourcing to experienced partners like Staffingly, Inc. can help reduce delays and improve outcomes. This article dives into the common challenges in prior authorization and offers actionable solutions to navigate these complexities with ease. By focusing on overcoming these obstacles, healthcare providers can ensure better patient care and operational efficiency.

Key Takeaways

• List the frequent problems that occur in the prior authorization process.
• Look for best practices to resolve these concerns in an effective manner.
• Explore the advantages of prioritizing governance outsourcing with Staffingly Inc to accelerate PA management and reduce errors.

Common Challenges in Prior Authorization

1. Incomplete or Missing Documentation

One of the most frequent causes of PA delays is incomplete or missing documentation. This occurs when essential records like recent office visit notes, diagnostic reports, or growth charts are not submitted.

Example:
In a real-world case, a prior authorization for a Growth Hormone Stimulation (GH Stimulation) test was delayed because the Bone Age X-ray and related report were missing from the submitted documents.

How to Overcome It:

• Make a list of essential documents particular to the service to be approved (for example, there may be requirements for office notes, diagnostic codes, and laboratory results).
• Instruct personnel to verify that the documents solved the requirement, before dispatching them to the payer.
• Have a common store of frequently requested material for timely managing the response process.

2. Complex Portal Navigation

Every insurance provider has its own portal, each with unique layouts and submission requirements. Staff often struggle with locating the right forms or navigating the portal efficiently.

Example:
In one scenario, a healthcare team struggled to locate the correct service type for outpatient GH stimulation tests in a payer’s portal, delaying submission.

How to Overcome It:

• Educate all employees on the usage of various portals including payor-related workflows and payor-related shortcuts.
• Create internal practice guides or checklists that describe the process of PA submission in detail for different payors.
• Engage teams like Staffingly, who have prior experience trained on various payer systems and portals.

3. Uncertainty About Payer Requirements

Payer requirements for PA can vary widely. Sometimes, it’s unclear whether a service requires authorization, leading to confusion and delays.

Example:
In a recent PA case, a healthcare provider wasn’t sure if Florida Blue required authorization for a diagnostic lab service, leading to back-and-forth inquiries.

How to Overcome It:

• Prior to commencing the PA protocol, consult updated payer-specific recommendations.
• Utilize automated tools or platforms that aggregate and refresh payer requirements.
• When in doubt, send an initial request with the intention that they confirm whether or not authorization is required.

4. Time-Consuming Follow-Ups

Once a PA is submitted, follow-ups often consume significant time. Providers frequently must contact payers to check the status or provide additional information.

Example:
A pending PA for a diagnostic lab service required multiple calls to the payer, with long hold times and repeated explanations of the case.

How to Overcome It:

• Monitor PAs through an integrated system where dates of submission, reference numbers and timing of follow ups are all recorded.
• Assign selected associates to follow up and keep direct communication with payers.
• Make use of qualified virtual assistants for follow ups such as those from Staffingly Free up your time to attend to patients instead.

5. Denials and Resubmissions

Denials often result from coding errors, insufficient medical necessity documentation, or miscommunication with the payer. Resubmissions can be both frustrating and time-consuming.

Example:
A PA for a new medication was denied because the ICD-10 code provided didn’t align with the payer’s criteria for medical necessity.

How to Overcome It:

• Keep track of coders that are schooled on proper ICD-10 and CPT coding.
• Focus on the explanation of the denial to make sure to fix whatever problems they might have identified in resubmissions.
• Team up with a team like Staffingly whose trained medical coders are able to mitigate risks of errors and even take off the pressure for resubmissions.

Outsourcing as a Solution to Overcome Challenges

Outsourcing prior authorization to a trusted partner like Staffingly, Inc. offers a comprehensive solution to these challenges. Here’s how:

1. Document Preparation: Staffingly guarantees proper collection and submission of all required documentation.
2. Submission Portal: Virtual assistants can work quickly and efficiently on submissions using payer portals.
3. Policy Compliance: Staffingly’s teams are continuously educated with payer rules, resulting in fewer mistakes.
4. Management of Follow-Ups: A seasoned professional undertakes the follow-ups thereby reducing the waiting time for approvals.
5. Claims and Denials: Using certified medical coders and billing specialists, Staffingly reduces the number of denials and achieves faster solutions.

By outsourcing to Staffingly, healthcare providers can save up to 70% on administrative costs while improving accuracy and reducing stress on their in-house teams.

What Did We Learn?

Prior authorization doesn’t have to be a bottleneck. By identifying and addressing common challenges—like missing documentation, portal complexity, and follow-up delays—healthcare providers can ensure faster approvals and better patient care. Partnering with a specialist like Staffingly, Inc. not only simplifies the process but also enhances efficiency and reduces operational costs.

FAQs

Q: What if a PA submission is denied due to missing documentation?
Review the denial reason, gather the missing documents, and resubmit promptly. Keep a checklist of required documentation to prevent this from happening in the future.

Q: How can outsourcing improve the PA process?
Outsourcing reduces administrative burden, ensures compliance with payer guidelines, and accelerates approvals by leveraging expert virtual assistants trained in PA processes.

Q: What’s the biggest advantage of outsourcing to Staffingly?
The biggest advantage is cost savings of up to 70%, combined with expertise in payer-specific requirements, which reduces errors and shortens approval timelines.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of healthcare processes. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com.

About the Author : Monica Michael is a seasoned Prior Authorization Specialist with years of experience in streamlining insurance processes for healthcare providers. She is passionate about simplifying complex administrative tasks to help hospitals focus on delivering exceptional patient care.