Payers Are Erecting Higher Hurdles to Care: How Can Hospitals Clear Them?

While prior authorizations are intended to reduce “unnecessary” procedures, they result in multiple burdens on providers and patients. To offset these losses, providers must often bill unsuspecting patients who are not prepared for the surprise bill for a covered procedure.

Providers expend a massive amount of time, effort, and cost into denials management as well as prevention strategies, including a dedicated team of authorization experts who attempt to stem the tide prior to service with faxes, phone calls, and web portals.

The technology to automate the bulk of the process is readily available, and the 278 transaction standard has existed for more than a decade. Due to payer reluctance to adopt electronic transactions, providers have looked to technology companies to build automation tools using Robotic Process Automation (RPA) and intelligent rules engines to navigate the ever-changing labyrinth of payer portals, rules, and requirements.