Revenue cycle management in the healthcare industry is one of the hardest jobs for revenue cycle leaders and healthcare administrators. Technologies like electronic health records (EHR) and patient management systems (PMS) have automated some of the workflows, but they do not cover every critical step.
Any healthcare provider offering services that require prior authorization from insurers will understand how quickly problems can arise. Without clear confirmation of whether a specific service has been approved, patient care may be delayed or coverage denied. Here is how revenue cycle management software like Adonis can help automate this part of the process.
Understanding The Gaps In Current Patient Management Software
There is no doubt that electronic health records and patient management systems have made work easier for healthcare professionals around the world. These tools give physicians and other authorized medical staff instant access to real-time, patient-centered records, including treatment histories and plans, medications, allergies, and laboratory information. Most also hold information about a patient’s health insurance.
Put simply, they help streamline a healthcare provider’s workflow. However, few EHRs and PMSs capture one critical element of the process – prior authorizations for specific medical services. Providers can use their existing patient management software to schedule procedures, but they have no way of confirming or clearly viewing authorization requirements.
Avoidable Insurance Coverage Denials
As a result, patient care and facility revenue suffer. A lack of prior authorization or pre-certification remains among the leading causes of insurance claims being denied. Statistics show that between 2016 and 2020 just over 11% of claims were denied because of prior authorization issues, making this the third most common cause for denial. Only registration and eligibility or missing and invalid claim data scored higher. By 2022, the figure had risen to 13% of avoidable denials.
When health insurance claims are denied, patients face large bills that they may struggle to pay. The stress associated with those may have detrimental impact on patient experience and satisfaction For healthcare providers, denials are equally stressful because of their impact on revenue management. Dealing with delayed payments and working with patients to develop payment plans or other alternatives is time-consuming. Plus, like the denial, this additional work could have been avoided.
Expanding the Benefits of Prior Authorization
The combined capabilities of Adonis’s Prior Authorization and Revenue Intelligence capabilities has expanded the scope of what each solution could offer alone.
It now provides healthcare providers with a centralized platform for verifying all necessary authorizations before services begin and a single source of vital revenue data. All of this makes it easier for healthcare providers to keep.
As an example, let's look at the potential journey of a patient scheduling an appointment to see a Dermatologist.
Before the appointment at the dermatology practice, Adonis will check to see if the patient’s insurance policy requires pre-authorization for the service. If so, it can then send a request to the insurer and confirm whether or not coverage has been approved.
The process is automated and seamless, taking away any guesswork. This ensures both the healthcare provider and patients know what services are covered before they arrive at the appointment.
Prior Authorization effectively eliminates the potential for denied claims or delays in payment due to lack of authorization, and with the addition of Revenue Intelligence capabilities, now provides an even more comprehensive suite of capabilities for medical providers.
Effective Revenue Cycle Management
All healthcare providers must adhere to insurers' guidelines while doing everything possible to track and receive payment for services rendered.
This is what makes Adonis’s Prior Authorization Revenue Intelligence capabilities so attractive; it helps to simplify the entire process.
With a single platform that automates as much workflow as possible, healthcare providers can reduce their administrative workload and free up staff for other tasks.
Having the ability to quickly check for prior authorization statuses and issues is just the first step. With a centralized platform to access vital front-end revenue cycle data, medical providers and front-office staff can streamline their workflows and better manage their cash flow
Some of the standout capabilities of these newly expanded Revenue Intelligence features for Prior Authorizations include:
- Key KPIs
KPIs (Key Performance Indicators) give healthcare administrators a snapshot of their income streams and the insights needed to ensure they get the maximum out of them.
Revenue Intelligence not only automatically gathers all relevant data but also incorporates critical KPIs, such as:
- Prior authorization denial rate
- Days to approval by the payer
- Number of denials per payer
- CPT code and location
By tracking these metrics, healthcare providers can see which services generate the most revenue and what areas need to be addressed to maximize their income streams.
- Detail Tracking for Days to Approval by Payer
Granularity is essential when it comes to tracking the effectiveness of prior authorizations.
Revenue Intelligence makes it easy for medical providers to view how long it takes different insurance companies to approve services and procedures, allowing them to tailor their strategy and ensure better outcomes.
- Showcase Alerts
Adonis' Revenue Intelligence tool makes this easy with its Alerts feature. By marrying proactive alerts with deep-dive analytics, Adonis is pioneering a renaissance in healthcare revenue management by proactively flagging prior authorization denials. Its emphasis on preemptive identification of issues, coupled with actionable insights, underscores its commitment to not just diagnose problems but to pave the way for sustainable solutions.
- High Submission Rates
Prior Authorization is capable of thousands of prior authorizations per month, depending on the size of a practice.
This ensures high submission rates and a much shorter turnaround time, resulting in better patient experiences and greater financial security for medical providers.
- Constant Refinement and Improvement
Adonis is constantly refining and improving its Prior Authorization Revenue Intelligence capabilities to help make the patient experience smoother while providing medical providers with the data they need to remain successful.
By using collected data in conjunction with the payer's published services on their websites, Adonis is able to programmatically refine the machine-learning rules engine powering its software, ensuring a constant positive evolution of the technology.
Benefits for Patients and Providers Alike
With Prior Authorization, medical providers no longer have to worry about denials or delays in payments, as they can quickly identify which procedures are covered beforehand.
Plus, with the ability to access vital front-end revenue cycle insights in a centralized manner, they have a comprehensive view of their revenue cycle performance
With its expanded Revenue Intelligence capabilities, Adonis’ Prior Authorization automation makes revenue cycle automation more accessible than ever, leading to a better experience for the patient and more effective revenue cycle management for the healthcare provider.