Prior Authorization Denials: EHR Tools to Secure ASC Payments
Posted by 1st Providers Choice on
The ambulatory surgery center, at its core, is a convenient option for surgical care. However, the prior authorization (PA) processes often create obstacles. Requiring clinics to contact payers before delivering services or prescribing medications leads to delays in both timely patient care and reimbursements.
This payer-centric system would work smoothly in an ideal world, but the reality is different. Physicians have reported that payers often take over two weeks to respond to PA requests or sometimes don’t respond at all. Even when they do, it’s frequently a denial—leading to a new round of paperwork from verification to resubmitting corrected requests.
Clinicians now have to spend more time on administrative tasks while patients anxiously wait to see if their care or medication will be covered. To address this issue, some ambulatory surgery centers (ASCs) have hired more staff to manage the growing admin burden.
In addition, many surgery centers have upgraded their electronic health record (EHR) tools to respond to PA denials. Take a deep dive into the impacts of PA denials and how EHR solutions can minimize these denials and enhance your ASC’s profitability.
Stop Revenue Leakage Due to Denials
The Impact of Prior Authorization Denials
The number of outpatient care claims being denied has increased by 16% over the past three years. Medical practices, including ASC surgeons, face significant challenges as almost 97% of providers experience delays or denials when submitting prior authorization requests.
In a comprehensive report, physician groups note that one of the root causes of denials was varying payer policies. Different insurance payers use various policies for PA, making it difficult for clinics to keep up with each payer’s specific rules and documentation needs.
“The prior authorization and MIPS requirements are especially burdensome. The good faith estimate requirements have added additional duties, but our Medicare payments remain flat or decrease. This is not sustainable for independent practices.”
~ Medical Group Management Association (MGMA)
Another factor behind frequent denials is some services and treatments that are generally accepted without issue still require PA. This point adds unnecessary administrative steps and can cause delays for services typically approved without hesitation.
How EHR Solutions Address Prior Authorization Challenges
Automated Prior Authorization Requests
An electronic prior authorization (ePA) module within an EHR can revolutionize the reimbursement environment for your facility.
By automating the prior authorization process, the ePA substantially decreases the manual workload while providing you with the following benefits:
- Streamlined workflow: The ePA system replaces time-consuming phone calls, faxes, and paperwork with a quick electronic request sent directly to payers.
- Faster approvals: Your patients receive their prescriptions faster by processing PA requests when prescribing.
- Broad compatibility: You can send requests for any plan or medication, ensuring your practice can efficiently handle all patient needs.
- Real-time tracking: With the ePA system, you can monitor the status of authorization requests in real time, giving your staff immediate visibility and control over the entire process.
Real-Time Eligibility and Benefits Verification
Some cutting-edge EHR software offers real-time eligibility and benefits verification. This tool helps your staff verify patient insurance details before or during their visit to your ASC.
Key features to look for in your verification tool include:
- Authorization verification: Authorization is verified at check-in and before posting charges to ensure the insurer pays for the procedure or medication.
- Pre-validation of encounters: Every patient encounter is pre-validated, preventing non-billable encounters (e.g., expired coverage or out-of-network services).
- Customizable requirements: Set authorization requirements by procedure and insurance so you can tailor the system to meet your ASC’s highly specific needs.
Integrated Medical Necessity Checks
Integrated checks compare the patient’s diagnosis, treatment plan, and medical history against the guidelines provided by insurance companies. This EHR feature helps reduce PA denials through:
- Efficient documentation: Medical necessity checks ensure that your billing or reimbursement staff includes all essential documents in the PA. This approach helps streamline the authorization process, especially for facilities where PA is actively tested by certain payers, including Medicare (California and other states with several ASCs).
- Preemptive validation: By ensuring that all orders meet medical necessity criteria before submission, the EHR reduces the chances of a PA denial due to insufficient or incorrect information.
- Real-time alerts: The system provides real-time alerts if a service doesn’t meet the payer’s requirements. Billing staff can adjust the order or gather additional documentation before submitting the PA request.
Enhancing Staff Efficiency and Reducing Burnout
Beyond automated ASC payment system processes, electronic health records support billing staff by:
- – Automating the documentation and coding process to reduce errors
- – Ensuring accurate claims submission and quicker reimbursements
- – Providing easy access to patient records for efficient issue resolution
- – Streamlining the entire billing process, from claim submission to follow-up
EHR systems significantly reduce the administrative burden on surgeons and physicians by automating routine tasks such as patient charting, prescription management, and scheduling.
EHRs also improve communication between different departments, minimize duplicate testing, and streamline the flow of information. This results in a more efficient care environment without putting you through frequent prior authorization denials and ensuing staff burnout.
Impact of EHR Tools on Revenue Cycle
To fully grasp how these technologies address PA denials, consider looking at your top competitor’s ambulatory surgery center payment system or EHR platform. Take a critical look at the numbers and processes:
- – How many PA requests can their tool process daily, weekly, or monthly?
- – How long does their PA process take for simple surgical procedures? How about more advanced procedures?
- – Is the software compatible with all major insurance payers and their varying requirements?
- – Does it comply with HIPAA or incentive programs, such as the Quality Payment Program (QPP)?
Checking software testimonials is another valuable method to learn how a tool improved a center’s reimbursement rates. This resource can also help you verify how the EHR system’s ePA feature helps minimize errors and boost ASC payments.
Take the case of billing manager Julie Ziehm, who struggled with bad debt before adopting 1st Providers Choice’s IMS EHR software:
“My bad-debt write-offs have been reduced over 90%. Pre-IMS, we had an average of $80,000 per month outstanding in charges waiting for a referral. Since the implementation of IMS, we have regularly maintained no more than $400 per month.
The authorization tracking screen helps us follow up with the insurance companies in a timely manner. The billing module is great; in a way, we now know what ensures timely payments. The aging reports help our billers set the priority of follow-ups, making sure we work in the right areas.”
Discover more successes like Julie’s! Check out automated prior authorization stories here.
Tap Into Our Expertise
As a facility providing surgical interventions to patients, your priority should always be the patients, not the payers.
By using automated PA requests, eligibility and benefits verification, and integrated medical necessity checks, you can address preauthorization challenges early and regain the resources necessary to provide the high-quality patient care your facility is known for.
Discover our ePA features and experience their impact on ensuring real-time prescription approval and patient satisfaction. Pair that with our real-time eligibility and benefits verification, and you’re well on your way to staying current with your ambulatory surgical center payment rates!
Call 480-782-1116 or contact our ePA expert to schedule a live demo at your convenience.