Case Study: Medical Prior Authorization Software for Healthcare & Insurance Providers

Industry: 

Overview

Client is a renowned health insurance organization in US.

Business Need

Client wanted to enhance prior authorization to be more efficient by standardizing the health insurance process and eliminate complexities. The prior authorization software should overcome all the challenges that hinder insurance process while addressing the patient health care. The pre approval process should be always aligned with a latest regulatory guidelines/principles recommended in US for health insurance system. Aim is to ensure timely and necessary care is received by patients and reduce all administrative hiccups.

Client Situation

Physicians & nursing staff realize that administrative burdens associated with current medical prior authorization requirements have increased exponentially in recent time. Physicians remains occupied with more clerical work than core patient care. Even, they wait at least a day or two for pre authorization process decisions from health insurance companies. Current system with vague design and opaque process lead to unnecessary administrative costs. Overall, current PA program have made an adverse impact on patient clinical outcomes. The solution prior authorization automation can reduce the frictions to improve synergy between health providers and insurers.

Technologies

  • Web Technologies: Liferay DXP 7.0 SP7, JAVA, MS SQL, Amazon Web Services Cloud Hosting

Recommended Solution

Our software analysts looked into fundamental issues of existing medical prior authorization process against prevailing US Healthcare guidelines. Team implemented the revised collaborative work flow solution to streamline medical prior authorization requests at various nodes like Physicians, Nurse, Administrative staff, Health Insurance companies and Pharmacy stores. Single web based work flow offered more transparency and efficiency coupled with fair costs.

Our automated prior authorization software had the following features:

  • Automated electronic Prior Authorization (ePA) platform
  • Data dictionaries to integrate latest Healthcare guidelines
  • Robust check for CPT-ICD specific eligibility and claims
  • Patient validation using EDI 270/271
  • Ensures accurate & secure data exchange
  • Relevant Medication Questionnaire
  • Integration with EHR
  • Integration with VerifyComply API call for out of network providers
  • Integration with PA Rules engine (Drools Integration)
  • Implementation of Letter Generation process (Docmosis)
  • Privacy assurance through HIPPA compliance
  • Approval decision alerts through SMS/Email/ Notifications
  • Options to re-submit the exceptions directly through same web interface
  • Advanced dashboard having reports to monitor and analyze medical prior authorization details

Result

  • Streamlined process to improve claim adherence
  • ePA can result in reduced costs and less labor for staff.
  • Staff can give more time for patient care
  • No more obstacles and additional costs
  • Reduced TAT to complete prior authorization request
  • Improved harmony between Providers and Payers
  • Patients are ensured accelerated access to necessary therapy

Frequently Asked Questions

What is Prior Authorization in Healthcare?

Prior authorization process means healthcare provider or hospital gets approval from the health insurance company before performing a specific medical procedure for you or prescribing a particular medication.

Why Automate Prior Authorization?

Healthcare staff remains occupied with more clerical work than core patient care. Even they need to wait a long time for pre-authorization process decisions from health insurance companies. So automation is very important to improve the prior authorization process to ensure timely and necessary care is received by patients and reduce all administrative hiccups.

What Information is Required for Prior Authorization?

There are different steps related to prior authorization information sharing but mainly patient’s doctor needs to submit necessary documents and reports to initiate review and pre-certification. Some important information includes the patient’s health condition detail, doctor’s provided prescription notes, and/or lab results providing detail about the patient’s condition and treatment history.

What is an Automated Prior Authorization System?

Automated prior authorization system allows healthcare facilities to increase the number of authorizations finished with limited time/staff, and less hassle. It helps Healthcare staff to give more time to patient care and their treatments instead of managing clerical work. The prior authorization automation also reduces the friction to improve synergy between health providers and insurers.

Client Speaks


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