Understanding Prior Authorization: The Key to Provider Frustration
Prior authorization is designed to confirm that some medical services (like prescriptions) are medically necessary and eligible for coverage on your health plan prior to you receiving these services. Although this process aims to facilitate appropriate patient care at a reasonable cost, it has created a significant "overhead" in the administration of many aspects of healthcare.
Standard operating procedures for many organizations require staff members to collect all the necessary clinical documentation; submit payer-specific forms; verify that the patient is eligible for benefits and to keep track of whether the payers have approved the requests — a process that may take several days or weeks to complete. Not only does this process delay patient care; it consumes a lot of time for the staff, introduces a great deal of the possibility for error, and may result in a claim denial if necessary criteria are not met. These inefficiencies also create unpredictability in cash flow for the providers and create friction between the providers and the payers.
Carevyn has developed a platform that targets the systematic friction in the prior authorization and benefit verification processes by automating numerous elements of the prior authorization decision and benefit verification processes. The automation results in expedited approvals and clearer view of the process from start to finish.
Carevyn’s AI Approach to Prior Authorization
Carevyn uses its innovative Artificial Intelligence (AI) System, which includes Natural Language Processing (NLP) and Secure Data Interoperability, to automate the traditional workflow for Prior Authorization. This means that all manual steps taken during the process today (interpreting clinical documentation, integrating payer requirements and communicating status updates) will now be done automatically with Carevyn's AI System, thus allowing for a more efficient way to create prior authorization requests and submit them to Payors.
Real-Time Eligibility Verification
By automating the process, Carevyn has eliminated the need to toggle between multiple payer portals and EHRs to check a patient's insurance coverage, as it has a built-in capability that allows uses to create and track authorizations immediately. Therefore, when a provider submits an authorization request to a payer and if that payer has received the authorization request but not responded, the provider will not have to go through numerous other systems to determine if it will be denied or approved; they can simply go directly to the Carevyn system to view the status of their request.
Carevyn's ability to automate the eligibility verification process saves time and eliminates many of the problems associates with implementing a traditional prior authorization process. It also enables providers to make very informed decisions when they are creating and submitting prior authorization requests.
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The Generation and Submission of Intelligent Forms
Using the clinical documentation (ex: Provider notes, encounter summaries), Carevyn's AI engine automatically populates prior authorization forms with the appropriate information, thus eliminating an unnecessary duplicate effort, while ensuring the submitted information matches what the payers expect and reduces the chances of submission errors leading to denials.
Additionally, Carevyn's Intelligent Engine intelligently identifies the appropriate payer and routes the authorization requests in real-time using the real-time logic provided by each payer. The result is significantly shorter submission timelines than prior methodologies. Staff can use the Carevyn solution to fully automate the process of identifying which forms should be submitted and to whom, and automatically track the approval status from one common area.
The Ongoing Track and Visibility into the Status of the Prior Auth Request
Prior to Carevyn, providers and administrative staff had little to no visibility into the authorization status of their request, with the need to check multiple payer sites, call to follow up with them, and rely upon the staff's recollection of authorization statuses. However, Carevyn's tracking of requests enables clinicians/administrative staff to track the status of their requests with real-time status updates via the EHR (Electronic Health Record) or through a centralized feature/dashboard, thus providing increased transparency into the request's progress without requiring staff to log into the EHR and other systems. As a result of this added transparency, providers no longer have unanswered questions regarding their authorization request status, substantially fewer manual follow-ups, and quicker response times from the payer.
Audit and Compliance Infrastructure
Carevyn's technical design is concerned with all records being appropriately tracked and available for compliant audit readiness. Every authorization request and authorized status change to the authorization is recorded in a manner that can be tracked and is in line with HIPAA/Risk and Regulatory Agencies compliance, helping to reduce risk and allowing compliance inquiries to be quickly reviewed without fumbling through paper-based artefacts.
Measurable Healthcare Workflow Impacts
The greatest value in fast-tracking prior authorization and back into the clinical workflow will be realized through evidence of the operational and clinical efficiencies. Carevyn will provide measurable return on investment benefits to administrative (bill and collections), financial (claims processing) and clinical (patient care).
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Faster Approval Timelines
Automation is the single most immediate and continued effect of Carevyn's technology on prior authorizations. Carevyn Customers have reported their prior authorizations ability to be completed; often 50% quicker than was previously required to get an authorization approved. Fast-tracked authorizations allow patients to gain access to medical services sooner, increase levels of appointment satisfaction, and decrease the length of time before patients receive needed treatment.
Having faster authorizations enables care teams to alleviate unnecessary delays, remove barriers caused by bottlenecks across scheduling with patients, and support resource planning. Thus, fast-tracked authorization times provide significant opportunities that improve operations in high volume practices and specialty clinics that are frequent users of prior authorizations.
Time Savings from Administrative Burden
Administrative staff are often on the receiving end of prior authorizations, which means the majority of the administrative staff's time will be invested in the management of the administrative process as opposed to revenue cycle management and billing.
Organizations that utilize Carevyn save hundreds of hours annually on administrative tasks through automated processing of key authorization requests. This time savings also translates into lower operating costs and enhanced ability to support additional functions in the revenue cycle.
Reduction in Denial Amount and Cleaner Claims
Because Carevyn provides both an integrated eligibility verification and an intelligent form population, claims submitted will have cleaner submissions on the first-pass. Providers will receive fewer denials due to authorization errors because claims that have been correctly populated from the outset allow billing teams to close claims more quickly; provide the organization with improved working capital; and reduce the number of resubmissions and appeals.
Improved Patient Experience
As prior authorization is no longer an impediment, patient journeys through care processes will be less disruptive. Patients will have access to procedures, medications and treatments quicker than if the prior authorization process were involved with other administrative duties.
Also, since back-office disruptions are lessened, there is lower risk of patients being faced with unexpected changes to their scheduled times or extended waits for medical appointments—both of which contribute significantly to a patient's overall satisfaction with his or her care and thus to the likelihood of retaining that patient for future services or treatments.
Integration and Technical Architecture
One of the main reasons that Carevyn has been able to provide an acceleration of the prior authorization process is the combination of a flexible and powerful technical architecture. Rather than trying to replace systems already in-place, Carevyn has built its solution with deep integration into the existing EHR Platforms and Payer Networks.
EHR Integrations That Are Seamless
Carevyn interconnects with all of the major EHR Systems (Epic, Cerner, Athena) so that the automation of this process occurs directly within the existing workflows of their clinicians and staff. Therefore, users do not have to go back and forth between different applications or learn new user interfaces. In addition, integration is achieved with speed and security; a large number of Health Systems deploy this solution in a matter of just weeks instead of months.
Safe Transmission of Healthcare Information
All health information in the U.S., regardless of the state in which it is received, is subject to specific requirements for protection and privacy. Carevyn supports these obligations by using established secure transmission protocols and standard encryption techniques to protect the Privacy of Health Information (PHI). All patient data and all authorizations and status updates related to patient data are processed. While protecting PHI, Carevyn also helps health care organizations maximize their efficiency.
Automated Workflow Solution
Carevyn is designed to grow and expand to meet the changing needs of its customers. Carevyn's automation engine can be scaled up to the requirements of large hospitals and multi-site health systems, as well as high-volume specialty medical offices. Carevyn's architecture is able to provide real-time processing of all three parts of the automation process — eligibility check, request generation, and status update tracking — without slowing down or holding up the processes.
Who is Most Likely to Benefit from Streamlined Prior Authorization?
Carevyn provides an Automated Solution that provides Value to the Entire Healthcare Continuum and creates many Opportunities for Value Realisation for Different Types of Organisations. However, The Largest Volume of Value Realisation will occur for the following types of organisations:
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Hospitals and Other Large Health System Organisations - Large Health Systems with higher volumes of patient population can benefit from a faster cycle for authorisation; Improved throughput for referred patients; and Less Administrative Cost for Authorisation.
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Specialist Clinics - Clinics that provide complex services and care (for example: Cardiology, Orthopaedics and Oncology) benefit from faster authorisation cycles, resulting in fewer delays to the delivery of care.
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Telehealth Providers - Providers of Virtual Services will have the ability to check In Real-time for authorisation and eligibility within Digital Workflows thus providing better and quicker responses for patients.
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Health Plans and Payers - Carevyn will enable Payers to offer In-Home Support Services by Reducing Abrupt Denials, Reauthorisation Requests and Reducing Member-Challenge for Accessing Healthcare.
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Durable Medical Equipment (DME) Suppliers - Suppliers of DME products will shorten the Cycle Time for Order to Payment by Cutting Out Waiting for Authorisation.
Real World Results – Success Stories of Carevyn Users
The case stories of Carevyn users demonstrate actual use and results of Prior Authorization Automated. In one instance, the medical group was able to reduce the time for completing a prior authorization from several days to approximately "real-time," and, consequently, the medical group staff was able to re-focus their efforts on patient-related activities. Clinical leadership in this medical group also reported that Carevyn allowed clinical teams to concentrate on the delivery of care rather than dealing with paperwork.
Another organization noted the use of Carevyn led to fewer claim denials and fewer administrative errors, leading to an improvement in cash flow and a reduction in downstream billing problems. Real-world examples such as these demonstrate that automation not only delivers better operational metrics, but also helps organizations meet their quality and compliance goals.
Carevyn's Solution for Overcoming Obstacles
Although all of the benefits that will be provided by automating health records will be tremendous, many health care systems have reservations about these benefits because of potential disruption of the current clinical workflows, issues with interoperability and change management.
Carevyn offers a number of solutions to help alleviate these concerns:
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Deployment With Minimal Disruption: The integrated deployment of Carevyn's platform into existing EHR systems may be set up with the minimal amount of disruption to the clinical workflows of the organization using the product.
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Artificial Intelligence Models That Are Highly Accurate: Carevyn's AI models have been trained using the clinical data and business rules of hospitals and health systems, resulting in an accurate and reliable generation of the forms and verification of eligibility.
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Dedicated to Compliance: Built in audit trails and secure data handling minimize the risk of regulatory violation.
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Scalable: The Carevyn platform has the ability to manage thousands of incoming requests at once without degrading performance.
Prior Authorization in Health Care: The Future of Healthcare Administration Through Automated Intelligence
As AI and automation are adopted by both payers and providers to simplify complicated back-end activities, the health care administration industry is quickly changing. This transformation has created a new expectation for an industry-wide standardized method of prior authorisation providing an efficient method of automating complex workflows.
As a result, clinicians and care teams are now able to complete repetitive workflow processes and focus on providing better patient-centered care by being able to make decisions based off of clinical judgement rather than paperwork. In addition, with faster approvals of prior authorisations, more predictable revenue cycles, fewer delays and ultimately improved patient experiences can all become reality if health care organisations are able to leverage Carevyn's automation and artificial intelligence-driven technologies today while positioning themselves for future advancements.
If your organisation has experienced high volume of denials and/or significant delays related to prior authorisations and also struggles with a cumbersome prior authorisation process, now is the time for you to consider exploring how Carevyn's automation will help eliminate those issues.
Please visit Carevyn's website today to book a demo and discover customised solutions for your organisation's healthcare setting and see the benefit of Carevyn's automation and artificial intelligence technology to reduce the amount of time spent in prior authorisation and improve the quality of care for your patients through the process of automating the revenue cycle.
Frequently Asked Questions
1.What Does Carevyn Automate That Is Associated With The Prior Authorization Process?
Carevyn automates the following aspects of prior authorization:
1. Eligibility Verification
2. Form Population
3. Payer Routing
4. Real-Time Status Updates
Carevyn also reads clinical documentation, auto-fills the required fields on forms, and tracks your Authorizations throughout the process, reducing manual work and turnaround times on approvals.
2. Will Carevyn Work With An Organization's Existing EHR System?
Yes, Carevyn works with the leading EHR systems (i.e., Epic, Cerner, Athena) and integrates automation into an organization's already established clinical workflow.
3. Will Automation Affect Compliance Or Audit Requirements For Organizations?
On the Carevyn Platform, you can maintain your compliance and audit ready logs. Carevyn's platform is compliant with HIPAA security rules, so all activities associated with prior authorization are trackable and match compliance guidelines.
4. How Much Time Does An Organization Expect To Gain By Using Automation?
Organizations are reporting very significant reductions in the amount of time spent on administrative tasks each year, with many organizations saving several hundred staff hours through automated eligibility verification, form generation, and status tracking.
5. Can Automation Reduce Claim Denials Related To Prior Authorization Errors?
Yes, Carevyn helps reduce errors that occur during the prior authorization process by accurately completing the authorization form and verifying the patient's eligibility in real-time, which results in cleaner first passes.