Hospitals that want to automate the authorization process face obstacles. “Currently, there are many payers who do not have a portal or website for electronic submission now, let alone automation,” says Pamela Carlisle, MHA, FHAM, CHAM, director of revenue cycle management at Genesis HealthCare System.
Criteria for securing an authorization is complex and varies by payer and employer. “Securing CPT codes that need approval with the correct diagnosis codes is often a challenge in today’s environment,” Carlisle reports.
Right now, payers use different criteria for the amount of time “conservative” treatment has to be tried before paying for more costly surgery. Third-party entities that serve as middlemen for payers add to the complexity. “Currently, some of the portals struggle with that communication,” Carlisle laments.
Patient access staff obtain the authorization from the third party, but, somehow, the health plan never receives this. There is no communication back and forth. Another large obstacle is the inability to track that the auth request was transmitted. Payer systems are not integrated with the hospital’s. “This is quite a challenge for our IT folks,” Carlisle explains.
The department started looking at automated authorizations several years ago. “It was fairly new at that time, and many payers were not ready,” Carlisle recalls.
Even for the handful of payers that could receive electronic requests, it was more trouble than it was worth. Duplicate responses to requests caused confusion and rework. “It took twice as much time to sort through it all and complete the auth than it did just completing it manually,” Carlisle says.
The department is using all available portals to expedite authorizations. About 70% of payers have some sort of online option. “But we are running into timing delays with payers and third-party intermediaries,” Carlisle notes.
Some payers require a 14-day turnaround time. “That is really not good service, from a patient perspective. Delayed care leads to increased anxiety,” Carlisle offers.
If auths really could be automated, “it would most definitely save time and improve patient care,” Carlisle adds. “Cost of care would decrease as well.”
About half of authorization requests to health plans are now automated at Aurora, CO-based UCHealth, but it was not easy to achieve this. “Our journey started several years ago,” says Kerre Valtierra, senior director for patient line.
The department started by optimizing the functionality within its existing registration system. “We were trying to figure out how to do this without adding cost to our budget,” Valtierra explains.
By doing that, the department automated about one-third of authorizations. It saved staff a great deal of time, but it was not enough. The department was handling many more authorization requests. “We were growing like crazy, and we needed to figure out how to do this better,” Valtierra recalls.
The issue became even more pressing during the COVID-19 pandemic. “Because of the financial climate that so many organizations are in, this is not the time to be adding FTEs to throw at a problem,” Valtierra offers.
The department had to find creative ways to increase the number of automated auths. First, leadership combed through a list of all services where an authorization had been obtained but the health plan actually did not really require an authorization. The list included outpatient procedures, clinic consultations, mammograms, and ultrasounds for various payers. The goal was to find a way to flag all those services so staff would not be wasting time obtaining authorizations that were not required.
Different locations within the health system held varying contracts with health plans. This meant criteria were not consistent on what required an authorization, even for the same health plan. The department came up with this test: “If a referral could not auto-authorize across the entire system — if that statement was not true at every location, then it simply could not be true,” Valtierra says.
If all payer contracts were the same, if all did not require an authorization for a particular service at any location, only then was it considered a “no auth required” service. “The second that order gets into the system and it’s signed, it auto-authorizes, and my team never sees it. It never hits the work queue for processing,” Valtierra says.
This dramatically reduced the number of orders that hit the work queues. Still, the volume of authorizations kept increasing. “We were continuously playing catch up. We could not hit our Key Performance Indicators, and our service level was suffering,” Valtierra reports.
Staff struggled to secure authorizations in time for the patient’s appointment. “We had to get innovative,” Valtierra says. “We asked, ‘Who’s doing this better?’ and ‘Does the technology exist?’”
The department searched for a vendor that had some type of automation for authorization. “We came up with a list of ‘must-haves’ that we weren’t willing to settle for,” Valtierra says.
First, the department wanted to stay within its EHR. There was no interest in a vendor that required staff to log into a separate portal or platform to submit an authorization request. “We were already logging into all of the different payers’ portals,” Valtierra says.
The department eventually found a tool that allowed authorization requests to be submitted through the work queues in Epic that staff was using already. “When we hit ‘launch,’ it goes into the payer portal from there, and inputs all the information from the order. We don’t have to manually put it in. It may sound minimal, but that was huge for us,” Valtierra explains.
Staff no longer have to enter the demographics, location, and CPT codes, reducing the number of data errors. “At the end of it, we either end up with an authorization and reference number or a denial,” Valtierra says.
Fifty-three percent of auths are automated. Previously, staff spent about 70% of their time following up on the endless auth requests. “It left us very little time to get to new submissions. We were functioning just a couple days out from day of service,” Valtierra says.
Now, staff are working seven to 10 days from date of service. The system automatically checks on the status of authorization requests at 5 a.m. and 2 p.m. If there is a reference number, indicating the request was approved, staff do not have to take any action. This frees up staff to handle only the authorizations they need to do something about. “We want to know what is happening so we can let the clinic know, and they can notify the patient,” Valtierra says.
Sometimes, the health plan wants clinical documentation before making a decision. Since staff are following up only on problematic authorization requests, the department can handle more accounts. “We onboarded dozens of specialty and primary care clinics to our department, solely because of the FTE offsets that we were able to realize because of this,” Valtierra notes.
Two new facilities and a surgery center were created without adding any extra staff. Still, not all “no auth” denials are caught. A denials review committee meets biweekly to discuss the few that do occur. “We review them, and we pay attention to that,” says Brent Rikhoff, UCHealth’s director for patient access.
The committee determines if staff marked it as “no auth required” inaccurately. Other times, they find out the health plan issued the denial in error. “The tool is only as good as the portal itself,” Valtierra says.
If there are technical difficulties with a health plan portal, the tool cannot help. Staff have to revert to their old process of calling the payer. “It’s not going to fix all frustrations. But it has helped us tremendously from a productivity standpoint,” Valtierra says.