Let’s take a look at what the manual prior authorization process looks like, typically the process begins when a prescription or procedure is submitted into an order entry system, the nurse, front office staff, biller or admin then identifies the patient and his or her insurance provider and needs to validate whether or not the prior authorization is required for the requested prescription or procedure and it takes at least 2 hours without implementing robotic process automation (RPA). 

Typically it involves the nurse, front office staff, biller, or admin accessing the insurance company’s online portal and browsing a list of prescriptions or procedures to determine whether the prior authorization is required. If it is determined that his or her prior authorization is required, the nurse, front office staff, biller, or admin will begin collecting the required patient information from various healthcare provider systems to populate the prior authorization requests once completed. The prior authorization form is submitted and routed to the insurance provider. This process is repetitive and cumbersome with a great deal of swivel chair data entry involved for the prior authorization specialists or nurses. Prior authorization is a prerequisite that your hospital or healthcare provider (specialist, clinic, and so on) gets reimbursement from the patient’s health care coverage plan prior to recommending a particular procedure or prescription for the patient or carrying out specific treatment. Without this prior approval, the patient’s medical coverage plan may not pay for your treatment, leaving the patient responsible or liable for the bill.

RPA-enabled prior authorization processes undergo the same steps as the manual prior authorization process. It’s just that RPA bots are much more capable of verifying patient health plans and their history to identify whether a particular service is approved by the health plan in a much faster and more efficient way. It takes approximately 2-5 minutes for an RPA bot to complete this process and also file the application on the respective insurance portal. 

If the health plan required any further information such as diagnosis reports and patient history or any doctors correspondence of the particular treatment, the bots will raise a query if it needs to be provided by the treating physician or if the records are readily available the RPA bots will go ahead and submit those records immediately preventing timely filing issues. The reason why we need to emphasize this is because most hospitals will be overwhelmed by the number of prior authorization denials or requests for additional information and might miss to follow up. The hospital might be responsible for not obtaining prior authorization in time.

For example, A hospital has more than 50 surgeries and inpatient volumes per week, and all these patients required prior authorization. Calculating the hours of successful action for filing authorization is 2 hours per patient, so on average manual prior authorization process requires 100 hours of manual work. The same process handled by RPA bots will take anywhere between 4-5 hours to complete the filing of authorization for all the 50 patients.

This saves lots of time which can reflect positively on the patient as they receive timely care and they may also refer other patients to your hospital increasing patient volume simultaneously. 

The Medical Group Management Association (MGMA) said the CAQH report affirms its own concern about the financial and staffing burdens of the prior authorization process and it directly affected the hospital and physician’s ability to perform the services required to the patient at the time of illness. The CAQH index identified and ensured that MGMA’s calculations uncovered that the expense for hospitals to physically produce a prior authorization request expanded from $6.61 in 2018 to $10.92 in 2019. Hospital cost for a similar process was reduced from $3.50 in 2018 to $3.32 in 2019. Simultaneously, the expense for hospitals and health systems to produce an RPA bots-assisted prior authorization transaction dropped from $2.80 in 2018 to only $1.88 in 2019, and the expense for hospitals reduced consistently year after year after implementing the robotic process automation for the prior authorization process. 

RPA-enabled prior authorization has proven results. It’s high time that hospitals and health systems adapt to the changing digital transformation that not only delivers quality, productivity and efficiency but also increases patient care satisfaction as they will be confident to rely on your hospital to perform the necessary due diligence. BillingParadise has certified RPA specialists who have experience both in programming RPA bots and healthcare RCM. Having this hybrid model allows us to answer all the questions related to implementing robotic process automation.

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