The prior authorization (PA) process emergency medical service (EMS) providers endure is a story of unintended consequences. Created as a utilization management tool for healthcare insurance companies to control costs and protect patients from surprise bills, it has unintentionally created heavy administrative burdens, increased claim denials and rework, and delays in care for patients. PA process challenges have a negative impact on EMS agencies’ financial performance and cause unnecessary stress for billing teams. Addressing the root causes of process delays, administrative bloat, and claim denials that lead to write-offs is complicated — especially with increasing PA demands from payers. The first step is to determine whether the payer requires PA, but rules differ from payer to payer, plan to plan, state to state, and the rules change frequently. Typically, dispatch isn’t checking for insurance requirements and will only submit a PA request if they know in advance that it’s required. Responsibility falls on billing staff to figure out whether PA is required or not. The process is highly manual and requires staff to search paper documentation, PDFs, and payer web portals. Staff must also review the PA requests and ePCRs, adding to the burden.

If PA is required, billing staff must track down coverage specifics pertaining to the level of service, care provided onboard, and more. They also must obtain a number, assigned by the payer, that corresponds to the PA request and include it when the final claim is submitted. Depending on payer, the timeframe after a non-emergent transport (NEMT) to submit a PA request may be anywhere from 24 hours to 90 days. The responsibility falls on the provider to continue to follow up with the payer until there is resolution of the request — an approval, redirection, or denial. Depending on the complexity, the level of manual work involved, and the requirements stipulated by the payer, a PA can take anywhere from one day to a month to process.

Delays and Denials Hurt Financial Performance 

PA delays and denials cause cash flow problems that have a ripple effect throughout the agency. When a PA request is denied, billers can appeal. Yet in the best-case scenario, revenue is delayed. If a request is denied, it’s often a Medicare or Medicaid account, and the claim is likely to be written off with a total revenue loss.

The complex and labor-intensive PA process robs the administrative team of time that would be better spent on higher-value activities. It contributes to healthcare worker burnout, and the unpredictable process disrupts workflows and hurts efficiency, adding to overhead costs.

Real-time PA Technology Can Alleviate the Pain in the Process

Fortunately, there is technology that can dramatically improve the PA process. Implementing tools that automate manual tasks can reduce the administrative burden and improve financial performance.

With the number of PA requirements expected to grow, finding a way to mitigate tedious, manual tasks through automation is urgent. Best-in-class PA tools leverage artificial intelligence (AI) to automate much of the process in real time, eliminating the need for portal searches, faxes, phone tag, and emailing.

Building upon automated eligibility and patient financial responsibility systems, EMS billing staff can add AI-enhanced, real-time PA technology to drive the end-to-end PA process as early in the revenue cycle as possible. Doing so reduces the likelihood for errors, slashes the amount of manual work wasted on tedious tasks, and accelerates patient care. It also adds invaluable functionality, such as the ability to automatically identify whether PA is required and to determine the optimal submission route.

A fully integrated, centralized approach includes:

• A master patient index (MPI) that can identify each unique patient
• Direct, real-time connections to most payers
• An extensive library of payer rules that synchronizes eligibility and PA rules
• Integration with workflows and systems like EHR, LIMS, health information system (HIS), and revenue cycle management (RCM) solutions
• A self-learning system that uses artificial intelligence (AI) to dynamically update automated workflow and rules engines based on the actual responses and results from submitted PAs
• Ability to integrate with automated revenue optimization tools, such as demographic verification, insurance discovery and verification, self-pay analysis, and deductible monitoring
• Ability to validate a PA request against payer guidelines, automatically submit it, and then receive instant decisions from the payer.

By streamlining the PA workflow, billing staff can collaborate more effectively with dispatch, improve productivity, and reduce the administrative headaches that contribute to burnout.

Although PA is complex, using an AI-enhanced, real-time technology like the ZOLL AR Boost® Prior Authorization tool integrated with ZOLL® Billing to automate manual tasks puts the focus back where it belongs: on compliantly capturing maximum revenue so the agency can continue to provide quality care to the community.

Read More About Time-saving Prior Authorization Best Practices:

Take the Pain out of Prior Authorization: Four Ways to Streamline Workflows, Preserve Revenue, and Improve the Patient Experience