Tag Archives: medical referral

Solutions That Help Hospitals To Increase Referral Profitability

Did you know health systems or hospitals lose up to 60% of patients to another hospital due to inefficient referral process?

What Hospitals Need To Do To Increase Referral Profitability?

Today most of the healthcare systems are functioning in silos due to disparate systems that do not communicate with one another effectively. It is a well-understood fact that the current referral process makes it difficult for patients to get the care they need. None of the health systems can afford to lose more than half of their revenue to referral leakage effects. However, with the advent of new healthcare technology, it is possible to improve overall efficiency, increase referral profitability and improve patient outcomes.

Health systems are now pursuing strategies to improve patient flow such as orchestrating the entire referral process. Rethinking patient referral workflow in hospitals is vital to improve patient experience, make operations more effective and increase referral profitability. They are thinking beyond departmental boundaries about the entire journey of the patient in the process, how patient appointments are made and how their clinical information are fetched/ tracked and how the referral loop is closed. It is highly important that they seal referral leakage, reduce no-show rates to increase referral profitability.

Three Major Reasons For Referral Leakages

Poor patient-provider communication: Effective communication between patient-provider has the potential to enhance patient satisfaction and health outcomes of the patient. On the other hand, poor communication can hamper the relationship and lead to referral leakage.

Lack of Provider-to-Provider Communication: All providers involved in patient care need to have a better and convenient medium of communication. Referrals through multiple channels can actually lead to poor referral management and cause referral leakage. Providers need to have a secure HIPAA compliant solution.

Complex Workflow: It is important for the workflow to be smooth and keep track of patients’ right from the time a patient is referred until the referral loop closure.  

The one-key solution to increase referral profitability and address all of the above would be to implement an end-to-end referral management solution. Analyzing the referral patterns can help yield more revenue opportunities and increase referral profitability. Understanding patient behavior, communication among physicians, practices, and locations is key in the referral process. Overall, effectively tracking the network should help patients and providers with informed decisions.

Two main attributes that health systems need to look for while choosing a referral solution are

Interoperability for new technology in unexpected ways in integrating with any EMR/EHR

Sustainable design and product features, which can solve the current challenges in the referral process

Product features that health systems need to look for while choosing a referral solution are

Multi-channel Referral Consolidation: Referrals from various sources need to be brought into a single queue for an easy process of referrals and this can help in avoiding referrals getting missed in the process.

Automated Insurance Pre-authorization: This process is an arduous time-consuming task and can affect the clinical outcomes of patients, doctors, and specialists. An automated insurance pre-auth can save time and help in processing more referrals.

Finding the right receiving provider within your network: Many health systems/ large hospitals are joint ventures or acquisitions. Finding the right specialist within the network may be a challenge as PCPs and specialists may not be aware of all the specialists within the network. A feature like this can help find the right provider.

Dashboard and Referral Analytics: It is difficult to track all referrals that flow in and out of the network. A referral analytics dashboard will help in understanding the referral patterns, a number of referrals and many more data for informed decision making.

Patient Coordination Framework: A patient-centered care coordination is required for better clinical outcomes and to reduce no-show rates. This feature will help patients, receiving providers and the referring providers are updated through the process until the referral loop closure.

With the above features, hospitals/health systems can expect the below benefits

  • Reduced patient no-show rates
  • Reduced referral leakage
  • Increased operational efficiency
  • Patient satisfaction
  • Increased revenue
  • Streamlined referral life cycle management

And at the same time gain better insight into the business using analytics such as the metrics dashboard, referral volume, referral patterns leakage rate, wait times, etc.

HealthViewX Referral Management is the right choice for large hospitals and health systems to keep track of patient referrals throughout the referral life cycle. Schedule a demo with us to understand the Solution features and benefits in detail and increase referral profitability. Our solution experts will be happy to guide you through our HealthViewX HIPAA compliant Patient Referral Management solution.


How Can Large Enterprise Hospitals Tackle Operational Problems Effectively?

Did you know? There are about 8000+ large enterprise hospitals in U.S. How is a hospital classified as a large enterprise hospital?

Hospitals which have typically 500 or more beds are categorized as Large Enterprise Hospitals. They are capable of serving the whole population in the community by offering them wide range of services related to primary care and specialties. Some larger hospitals offer a combination of acute and long-term care services while also providing research opportunities in some cases and accommodating a variety of specializations.

Operational challenges faced by  Large Enterprise Hospitals

Considering the huge number of patients in such hospitals, the patient referral volume is also high. In order to improve patient satisfaction and retain patients within their network, a large enterprise hospital must have a seamless referral process. Below are the most common operational challenges that affect the patient referral workflow in large enterprise hospitals.

  1. Handling multiple EMR/EHRs – Large Enterprise Hospitals and Health Systems that are formed as part of mergers and/or acquisitions tend to handle multiple EMRs. They  spend millions of dollars having to migrate from one EMR/EHR to another. It is also possible that if one EHR faces a down time, the entire patient referral workflow is affected. Data security in communication between multiple platforms is crucial to protect patient interests. In a merger or acquisition, patient experience must never be compromised despite the backend operational challenges that may occur. Seamless functioning between EMRs like Cerner, Athena Health, Greenway Health, Allscripts, Nextgen, etc is important.
  2. Training their staff – Staff in each division in the hospital might be comfortable with using a different EMR system. The user interface and familiarity affects speed of operations. The health system has to train and migrate all staff to a single EMR which costs millions of dollars and time to get the staff up-to-speed.
  3. Patient no-show rates – When patients miss/forget or do not show up for appointments, it results in revenue loss for the hospital. Patients miss appointments due to various reasons like no reminders, waiting time, better specialist within the locality, reputation of the receiving provider, etc.
  4. Referral leakage – Did you know? Referral leakage for large health system can average anywhere from 55-65%! Patient leakage or referral leakage occurs more in an out-of-network referral than in an in-network referral. Enterprise hospitals use different systems to track out-of-network and in-network referrals. There could be many factors like reputation of provider, lack of knowledge or insight and patient’s choice that lead to patient leakage.
  5. Patient dissatisfaction – Large enterprise hospitals should keep in track of the number of patients moving out of their network. An alarming 25 to 50% of referring physicians do not know whether their patients see the specialist! Patients become dissatisfied with the treatment when specialists or PCPs do not follow-up with them regularly.
  6. Referral Analytics –  As a large number of referrals flow in and out of the network, it is difficult to track the exact number. It is also tedious to track the number of referrals in various status, referral loop closures, percentage of referrals flowing in and out of network, referrals sent to different specialities, insurance provider, etc.

HealthViewX Patient Referral Management Features for Large Enterprise Hospitals

In order to solve the operational challenges faced by large enterprise hospital, the process has to be improvised. This can be done with web-based referral management which will optimize patient satisfaction and care.

HealthViewX has completely analyzed the workflow of large enterprise hospitals. We have implemented the following features for many of our enterprise hospital clients thus improving their operational efficiency

  • Multi-channel referral consolidation – The HealthViewX solution can capture fax, phone, email, online form referrals or any other referrals in a single interface. It makes it easy to monitor and manage all channels of referrals in a single queue.
  • Insurance pre-authorization process HealthViewX automates the insurance pre-authorization process. The provider need not coordinate with the insurance company for prior authorization. The HealthViewX solution will do it for them. This reduces the manual effort of the referral coordinators.
  • Patient coordination framework – After finding the receiving provider, the referral coordinator refers the patient. When the receiving provider receives the referral, the provider will get notified of the referral. Even the patient will be notified of the referral. The receiving provider can schedule appointments based on the patient’s comfort. This will cut down patient no-show rates.
  • Timeline View to track referralsWith the help of a referral status, the referring provider can get to know what stage the referral is. A timeline view shows a history of stages through which the referral has progressed. The chances of a referring provider missing out on referral updates are very less.
  • Referral closure and feedback – The referring provider can close the referral when it gets completed. The receiving provider and the patient can give a feedback on the referral process to the referring provider. Thus the referring provider can make it easy for the other the next time.
  • Referral Analytics – Helps in tracking the number of referrals and gives complete information about the referrals processed, missed, scheduled etc with the help of a Referral Data-centric Dashboard. It can also be customized for different locations based on the priority of the enterprise hospital.

HealthViewX Patient Referral Management solution smooths the referral process and solves most operational challenges for Large Enterprise Hospitals. Do you want to know more about HealthViewX HIPAA-compliant Patient Referral Management solution? Schedule a demo with us.







FAQs – Chronic Care Management

Care providers across the United States of America are monetizing Medicare chronic care management billing reimbursement codes to increase revenue from their practice. Read on to find answers to all the most commonly asked questions about patient eligibility, the scope of services, CPT codes and payment reimbursement for Medicare CCM.

Patient Eligibility

FAQ: Are all Medicare patients eligible for CCM reimbursement?

AnswerAccording to the Centers for Medicare & Medicaid Services (CMS), CCM is for “patients with two or more chronic conditions. A chronic condition is expected to last at least 12 months or the patient’s entire lifetime. The condition should be diagnosed to place the patient at significant risk of death, or functional decline.

FAQHow can a care provider decide which condition meets CMS’ definition for CCM eligibility?

AnswerCMS has not specified or listed the eligible chronic conditions that meet this definition. CMS does have a databank regarding chronic conditions (http://www.ccwdata.org) that care providers can use. However, this list is very narrow. In general practice, CMS requires a clear communication within the care plan that the chronic conditions being treated post a significant risk of death or functional decline.

FAQ Are there only certain diagnoses for which the CCM code can be reported?

Answer: There is not a defined list of diagnosis codes that meet the requirements of. What is required is that the chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline and that management requires a care plan. The AAN recognizes patients with two or more of the following conditions may be appropriate for the use of chronic care management services*:

  • Neurocognitive disorders including Alzheimer’s disease, Dementia, and Parkinson’s disease
  • Stroke with late effects that place the patient at risk for falls, fractures, and aspiration pneumonia
  • Poorly controlled diabetes mellitus

FAQ: What about patients who are Medicare beneficiaries but also eligible for Medicaid?

Answer: CMS CPT codes can be used while billing for CCM treatment given to Medicare beneficiaries who are also eligible for Medicaid.

FAQ: How to kick-start the process of bringing a patient under CCM care?

AnswerAn initial appointment must be fixed for a comprehensive evaluation of the patient. This is known as a “Welcome to Medicare” visit and includes an initial preventive physical examination. A patient must have received an introduction to Medicare CCM billing in person to be able to bill separately for CCM services. Until the changes made in 2017, a consent form signed by the patient was mandatory during the patient’s initiation into the CCM program. As per the CMS requirement, the consent form is no longer mandatory.

FAQ – Can CCM services be reported if the patient/caregiver has not given consent?

Answer: No. One of the requirements for billing CCM services is “knowledge and recognition by the patient that the physician will perform care management services on the patient’s behalf.” In the event of an audit, documentation of patient consent in the patient record is crucial.

Scope of Services

FAQ: What are the scope of services for CCM reimbursement as defined by CMS?

AnswerCMS defines the scope of CCM services in the following way:

  1. Provide patients with access to care management services at any time of the day. This means patients should be able to contact the care provider during any emergency or urgent chronic care need 24-hours-a-day, 7-days-a-week. This may be through calls, SMS, email, internet applications or other means agreed upon by the patient and care provider.
  2. Established care continuity with a designated provider with whom the patient is able to schedule appointments, discuss care plan compliance, report vital stats and discuss any discomfort that arises.
  3. Creation of a patient-centered care plan document taking into consideration the physical, mental, functional and environmental factors of the patient. This includes an assessment of the support system and resources accessible to the patient.
  4. Care management for chronic conditions including assessment of patient’s medical, functional, and psychosocial needs. Regular follow-ups to ensure timely receipt of all recommended preventive care services, adherence to the suggested care plan and timely medication.
  5. Regular follow-up after a patient visits the emergency department, after discharges from the hospital or other healthcare facilities. Coordination with home/community based clinical service providers to support a patient’s care plan adherence.
  6. Use of certified electronic health record (EHR) and a patient consent form were mandatory until the changes in 2017 which made them optional.

Chronic Care Management CPT Billing Codes and Payment

FAQ: Which CMS Medicare billing codes can be used to bill CCM?

Answer: For the chronic codes that can be billed are below.

CPT Code Billing Amount(approx) per consultation Description
CPT99490 $42 Min 20min non-face to face time monitoring the care plan
CPT99480 $60 Min 60min non-face to face consultation time establishing or monitoring a care plan
CPT99489 $47 To be billed with CPT 99487 for every additional 30 min of non-face to face consultation

FAQ:  Are CCM services subject to Medicare’s co-paying system?

AnswerYes. After the deductible is met, the 20 percent coinsurance charged to the patient will be about $8 to $9 for a month’s work of CCM with CPT 99490.

FAQ: Can you bill CCM for patients in an assisted living facility?

AnswerAccording to CMS, CPT code 99490 can be billed only for CCM services provided to a patient who is currently not the inpatient of a hospital. The patient must not be residing in a facility that receives payment from Medicare for that beneficiary.

FAQ: Is billing for CCM services limited to primary care physicians?

AnswerPhysicians and Non-Physicians can claim reimbursement by billing for CCM CPT Codes. CCM code is most likely to be billed by primary care physicians. However, specialists, nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives who meet the requirements may also bill for these services.

FAQ: Can the non-face-to-face time spent creating the care plan count toward the 20 minutes necessary to bill 99490?

AnswerYes, it can.

FAQ: What is the difference between chronic care management (99490) and complex chronic care management services (99487, 99489)?

Answer: Complex chronic care management services include the same criteria as the chronic care management service, plus an additional requirement of the establishment or substantial revision of a comprehensive care plan, medical decision-making of moderate to high complexity, and at least 60 minutes of clinical staff time.

Care Plan

FAQ: What does the care plan have to include as required by CMS?

AnswerThe plan of care should include details of the following elements:

  • Problem list detailing the chronic conditions the patient suffers from
  • Expected outcome and the likely course of the disease
  • Measurable treatment goals
  • Symptom management
  • Planned interventions through regular follow-ups and vital data collection from patient
  • Medication management depending on any concerns/reactions/improvement reported by the patient
  • Care coordination plan between care provider and patient’s caregiver such as family/nurse/community housing etc
  • Requirements for periodic review and revision of the care plan as required.

FAQ: Do I have to provide the patient with a copy of the care plan?

AnswerYes. CMS requires the care provider to share the care plan with the patient in a written or electronic format.

FAQS – Patient Referral Management

There has been a buzz around Patient Referral Management recently. Practices have considerable concern about how Patient Referral Management works and the related organizational components. This blog documents the Frequently Asked Questions by general practices in the U.S. and answers for the same.

FAQ – What is Patient Referral Management?

Answer – Patient Referral Management is the process of monitoring, directing and controlling patient referrals. It varies according to the nature of a practice and encompasses a range of different functions. Referral management centers may send referrals to specialty care or receive referrals from primary care. In addition to analyzing patient referral data, it also includes

  • Patient appointment scheduling
  • Communicating referral updates to the physicians
  • Referral process feedback
  • Referral loop closure

FAQ – How does a Patient Referral Management work?

Answer – It can vary depending on the nature of a practice. When patients need advanced treatment or additional diagnosis that cannot be given within the practice, they are referred to a specialist/imaging centre. The PCP identifies the need for a referral and places a request with the referral coordination team. The referral coordinator does the insurance pre-authorization and finds the right specialist for the referral. Then the referral coordinator sends the referral. Now the specialist validates the referral information and coordinates with the referring physician for missing information. The specialist then schedules appointments and takes care of the patient. The specialist must give timely updates to the referring physician. After the referral is over, the referring physician closes the referral loop.

FAQ – What are the medico-legal risks?

Answer – Some of the possible risks involved in a Patient Referral Management process include:

  • The referral letter getting lost in the process
  • Delays in the patient being seen by a specialist
  • The patient being seen by an inappropriate specialist (at the behest of the RMC)
  • The referral being returned to the practice when it is, in fact, needed
  • Whether referring through Patient Referral Management may breach patient confidentiality.

FAQ – Is patient confidentiality at risk?

Answer – In line with General Medical Council advice, practices should tell patients if their referral letter will be sent via a referral management centre.

Paragraphs 25-27 of the GMC’s Confidentiality (2009) state

  1. Most patients understand and accept that information must be shared within the healthcare team in order to provide their care. You should make sure information is readily available to patients explaining that, unless they object, personal information about them will be shared within the healthcare team, including administrative and other staff who support the provision of their care.
  2. This information can be provided in leaflets, posters, on websites, and face to face and should be tailored to patients’ identified needs as far as practicable. Posters might be of little assistance to patients with sight impairment or who do not read English, for example. In reviewing the information provided to patients, you should consider whether patients would be surprised to learn about how their information is being used and disclosed.
  3. You must respect the wishes of any patient who objects to particular information being shared within the healthcare team or with others
    providing care, unless disclosure would be justified in the public interest. If a patient objects to a disclosure that you consider essential to the
    provision of safe care, you should explain that you cannot refer them or otherwise arrange for their treatment without also disclosing that

If the patient objects to the involvement of the RMC, the practice should respect their wishes and make the referral direct to the consultant, if that is possible. The referring practice should, however, be able to rely on a duty of confidentiality at the RMC which is comparable to their own.

FAQ – Why go for a Patient Referral Management software?

Answer – Patient Referral Management process is currently too manual and requires a lot of time and effort. A Patient Referral Management software helps in automating the process. It eases the process of,

  • Insurance pre-authorization
  • Finding the right receiving provider
  • Patient coordination and communication
  • Referral updates to the referring physicians

FAQ – Whom does a Patient Referral Management Software benefit?

Answer – A Patient Referral Management Software helps in automating the manual process of managing patient referrals. It benefits all the stakeholders involved in a referral process. They are,

  • Referring physician – A referring physician identifies the need for a referral and initiates the same. A Patient Referral Management Software reduces the processing time of the referrals. It saves a lot of time and effort for referring physicians.
  • Referral coordinators – Referral coordinators do the insurance pre-authorization and also they also find the right specialist. They are made to handle many software at the same time. A single Patient Referral Management Software can help in easing the process for them.
  • Receiving providers – The specialists have tough time managing referrals from various channels and also fail to communicate effectively with the patient and the referring physicians. A Patient Referral Management Software can automate the process by channelizing the referrals into a single queue and also help in effective communication.
  • Patients – A software can help patients by reducing their efforts in communicating between the referring and receiving providers. It also enhances patient experience by reducing care fragmentation.

FAQ – Which organizations can use a Patient Referral Management software?

Answer – A Patient Referral Management software can help organization who send or receive referrals. Community Clinics and Federally Qualified Health Centres (FQHCs) send out referrals. They can use a Patient Referral Management software to track and manage their referrals. Specialist clinics and Imaging centres who receive referrals can use this software to manage their referrals and patient appointments efficiently. Large Enterprise Hospitals send and receive referrals. They can use a Patient Referral Management Software to track how many referrals are flowing in and out of their network.

FAQ – Does a Patient Referral Management software help both inbound and outbound referrals?

Answer – Inbound is when referrals are received in a practice and outbound is when referral are sent to a practice. As mentioned earlier, a Patient Referral Management can help in both sending and receiving referrals. Both inbound and outbound heavy practices can benefit from a Patient Referral Management software.

FAQ – How to implement a Patient Referral Management software?

Answer – A Referral Management software must identify the pain points in the current workflow and try to fit in by solving the challenges. For instance, before our HealthViewX Patient Management software is implemented, we do a few steps,

  • Understand the practice’s challenges and what they predominantly need to solve
  • Study the practice’s workflow completely
  • Propose a solution wherein it can fit in their existing workflow
  • Implement the solution without disrupting their existing system

Ideally, any Patient Referral Management software should follow the above for easy implementation.

Improve Your FQHC’s Operational Efficiency And Increase Your Revenue

Money inflow is very important for medical practices. Without a constant source of revenue, medical practices cannot pay bills, pay employees or take care of patients. It is no different for Federally Qualified Health Centers.

What are FQHCs and how do they operate?

FQHCs are community-based primary care medical practices. They provide comprehensive health care services for people of all ages, regardless of their ability to pay or health insurance status. They form a critical component of the health care safety-net as they provide

  • Primary care
  • Preventive care (oral health and mental health/substance abuse) services

FQHCs are also called Community Health Centers, Migrant or Homeless Health Centers, and 330-Funded Clinics.

The mission of FQHCs is to enhance primary care services to the underserved in both urban and rural communities.  They operate as nonprofit entities under the guidance of a board of directors selected from the community where they operate.  In return for providing care to the underserved and uninsured, FQHCs receive Federal government cash grants, cost-based reimbursements for their Medicaid patients, and malpractice coverage. These practices not only maximize the effect of the federal investment going to local patient care but also expands the impact of the Medicaid and Medicare programs.

Why should FQHCs concentrate on improving operational efficiency and increasing revenue?

FQHCs play an important role in supporting their community and providing care services to the underserved. Due to this, they may experience financial issues at uncertain times. When budgetary resources are strained, it is critical for an FQHC to

  • operate with maximum operational efficiency
  • preserve financial security
  • maintain staffing levels to continue operations

Inefficient and improper business processes will lead to patient dissatisfaction which will result in patients leaving the practice. FQHCs must concentrate on

  • Maximizing their business and staff efficiency
  • Minimizing financial risks

How can FQHCs improve operational efficiency and increase revenue?

FQHCs can improve business effectiveness and operational efficiency by making sure they follow these essentials steps.

1. Web portal for patients

It is important for FQHCs to take good care of their patients. Factors such as waiting time, improper schedules, referring to the wrong provider, etc create patient dissatisfaction. In order to prevent these, FQHCs should implement a web portal for their patients. Using the web portal, patients can access their health records, appointment schedules and choose providers based on their interests and preferences. When patients have the liberty to choose providers whom they can be referred to and also the appointment slot, they will show up for the appointments. Through this way, FQHCs can reduce patient-show rates, decrease referral leakage and also improve patient satisfaction.

2. Using technology

FQHCs prefer working with EMR/EHR systems because they are comfortable with it. So they do not wish to move out their EHR/EMR system. An EHR/EMR system has many advantages but when it is complemented with a Referral Management software practices can experience many more benefits.

How great it would be if a Patient Referral Management software could integrate seamlessly with an EMR/EHR system? It can help in ensuring end-to-end Patient Referral Management without disturbing the existing system.

HealthViewX Patient Referral Management solution provides easy steps to integrate with a practice’s EMR/EHR system. The patient demographics, diagnostic reports, test results or any sensitive information can be transferred safely. The solution is HIPAA-compliant with complete data security.

3. Improving staff behaviour

FQHCs must make sure that the people operating their front desk are friendly enough to deal with customers irrespective of their class status or bank balance. The more welcoming they are, the more the patients will feel comfortable and at ease.

Moreover, operational efficiency is the key to success. The more efficient the front desk operations team is at an FQHC, the more practice revenue the FQHC can generate. It can also help them facilitate additional patient visits; which mean that if more patients are adjusted and facilitated, the FQHC has the potential to make more money.

HealthViewX Referral Management Solution to aid FQHCs

HealthViewX Patient Referral Management Solution has the following features that aid FQHCs in improving their operational efficiency and referral workflow.

  1. Outbound Referrals – HealthViewX Referral Management Solution can integrate with both the receiving and referring end. For inbound referrals, it helps in channelizing various sources into one single queue. In case of outbound referrals, it facilitates integration with the existing system to read the patient data and send out referrals.
  2. Referral Timeline – In HealthViewX Referral Management System, any referral has a timeline, to capture and notify the progress of the referral to all the stakeholders. A referral will be mapped to a status which helps in tracking it better. With this, the providers can always be aware of how the referral is progressing.
  3. Workflow and Task Management – A workflow can be defined on how the referral flow must be(business rules). Tasks can be created to manage referrals by assigning it to the respective person.
  4. Improved communication – HealthViewX Referral Management Solution supports messaging and calling features for the referring and the receiving providers to stay connected.
  5. Data Management – The solution is HIPAA compliant and enables secure data exchange of all patient-related documents.
  6. Seamless Integration – The solution can seamlessly integrate with any EMR/EHR/RIS or Third Party application thus providing minimal disruption in the existing referral flow.
  7. Referral History Consolidation – The consolidated data regarding the referrals and the referral history of any patient can be printed as a hard copy at any time in pdf/excel.
  8. Smart Search – HealthViewX Referral Management solution has a smart search facility that helps in finding the right provider for the treatment required.
  9. Referral Data Analytics – Referral data-centric dashboard gives complete data regarding the number of referrals flowing out, the number of referrals in various status, patient follow-ups, etc.

Having Trouble Maximizing And Managing Revenue?

Are you an FQHC facing difficulties in managing your business operations and workflow? Then you may have a revenue cycle problem. HealthViewX Patient Referral Management Software is custom-made to solve the challenges faced by FQHCs. Schedule a demo to know more about our solution!

All You Need To Know About Insurance Prior Authorizations In Healthcare

Insurance Pre-authorization in healthcare

Prior authorization is the talk of the healthcare industry since the increase in specializations in healthcare. Any healthcare process has its own pros and cons. Prior authorization is no exception to that. A Health Insurance Company must verify if the patient is eligible for an insurance for a certain drug or procedure. Before the physician prescribes it to the patient, it is a common practice to parallely check for authorization from an insurance company. 

Current Healthcare Insurance Prior Authorization (PA)  Workflow

  1. The physician recommends a lab test – A patient visits a physician complaining of leg pain. The physician suggests the patient get an X-ray to know what is causing the pain.
  2. The lab receives the order – The lab receives the request for the test and initiates the process of prior authorization.
  3. Lab conducts PA – A separate team is dedicated for PA in most of the labs. They check the PA requirements, health plans, etc. They retrieve patient-specific data like the history of medications, diagnosis done, etc
  4. Insurance agents review Prior Authorization – Lastly, the insurance agent reviews and validates the documents sent as a part of the PA process.

The ultimate aim of PA is to optimize patient outcomes by ensuring that they receive the appropriate medication thereby reducing

  • Wastage
  • Errors
  • Unnecessary prescriptions and drug use
  • Cost

Problems presented by the process of Insurance Prior Authorization

1. Time taking process for doctorsPhysicians are dissatisfied with the time their staff has to spend interacting with health plans. When a procedure needs authorizing, it consumes a lot of admin time. It includes the time a physician spends persuading an insurance company to cover an expensive medication or a procedure. For most PA, physicians have to follow multiple steps. This involves

  • securing the correct form
  • filling it out with the required information
  • submitting the form to the plan

Physicians say that the overall process takes 30-45 minutes for each PA submission.

2. The cost involved in Prior Authorization – Though PA is the most talked about topic in the healthcare industry, little is known about its cost. In 2009, a study by Health Affairs estimated that on average, prior authorization requests consumed about 20 hours a week per medical practice

  • one hour of the doctor’s time
  • six hours of clerical time
  • 13 hours of nurses’ time

It further revealed that when the time is converted to dollars, practices spent an average of $68,274 per physician per year interacting with health plans. This equates to $23 billion and $31 billion annually! Prior authorization ultimately ends up costing the health care system more than it saves.

3. Patient delayThe real impact of PA is often felt by patients whose treatment is delayed. Nearly all physicians noted that wait times increased the delays in necessary care, which added to the risk of adverse events. According to AMA, a PA decision takes at least one business day for 64% of physicians and 3 or more business days for the rest. During this time, patients are unable to start treatment. These long wait times have a negative impact on patient experience and patient care.

4. Management of Prior AuthorizationThe management of PA can sometimes be difficult to manage. This is because the requirements can vary widely from one insurer to another. Each one has a different process for submitting prior authorization requests. The process cannot be standardized at times and must be done manually. This will of drain resources and time if this is already limited.

How can the Insurance Prior Authorization process be improved?

Healthcare Insurance Prior Authorization is a necessary step in many practices. But the current process is all too often manual and involves a cumbersome workflow. It may result in delays in treatment and dissatisfaction for patients and medical practitioners. As a result, many are implementing electronic prior authorization solutions to address common issues with the approvals process.

HealthViewX Referral Management solution makes the referral workflow easy for the practices. It has the following features that make the process of Prior Authorization simpler.

  1. EMR/EHR integrationOur System integrates directly with electronic health records (EHRs). This enables healthcare professionals to easily obtain prior authorizations in real time at the point of care. It also eliminates time-consuming paper forms, faxes, and phone calls.
  2. Timeline View – Both the center and the PCP can view the timeline data of the patient in which the referral history is present. Documents and notes can be attached anytime for one another’s reference.
  3. To and fro Communication – At any time of the referral process, the PCP and the center can communicate with the help of the inbuilt secure messaging and voice call applications.
  4. Referral Data Consolidation – It has options for printing the consolidated data about the referrals and the referral history of any patient as a hard copy at any time in pdf/excel.
  5. Secure Data Management – HealthViewX Patient Referral Management is HIPAA compliant. It manages all patient-related documents securely.
  6. Referral Analytics – Helps in tracking the number of referrals and gives complete information about the referrals processed, missed, scheduled etc with the help of a Referral Data-centric Dashboard.

HealthViewX Patient Referral Management solution helps practices in managing their prior authorization process and saves their time and money. Are you a practice looking to ease your prior authorization process? To know about HealthViewX Patient Referral Management System in detail schedule a demo with our team.