In the face of manual PA proliferation and pressure from the value-based care model, the need is growing for real-time electronic PA systems that will ease the administrative burden on stakeholders throughout the healthcare ecosystem.
How a Real-Time Automated Decision-Support Tool Can Cure the Prior Authorizat...Cognizant
A collaboration between Cognizant, the New England Healthcare Exchange Network and Informatics In Context is demonstrating how a real-time prior authorization (PA) system for medical and administrative processes saves time and money.
White Paper - eCQMs: It's Time to Make Data Quality the No. 1 Priority Q-Centrix
This white paper will examine eCQM data quality issues and their implications. It will raise questions hospitals should consider when developing strategies to improve their eCQM capabilities. Lastly, it will outline how they can benefit from implementing better data quality control practices and present new developments in eCQM data collection and reporting.
PYA Highlights Next Steps of Meaningful UsePYA, P.C.
At the 2013 AICPA Healthcare Industry Conference, PYA Principal David McMillan and Senior Manager Chris Wilson recently explored the “new normal” of meaningful use as compliance and strategic standards in new care/reimbursement-model development.
NCQA’s Accreditation process provides payers with a comprehensive framework to improve quality of care and services. It allows members and employers to compare health plan performance across various plans and against industry benchmarks. NCQA accreditation has 3 parts – HEDIS, Patient experience CAHPS measures and NCQA standards
Current Trends in Data Protection for Integrated Health, Centralized Peer Rev...PYA, P.C.
A webinar hosted by PYA and the Alliance for Quality Improvement (AQIPS) explored “Current Trends in Data Protection for Integrated Health, Centralized Peer Review Systems, and Other Innovative Programs.” PYA Principal Martie Ross participated in the webinar, which focused on how patient safety organization (PSO) protections can bring value to accountable care organizations and other integrated health systems.
In addition, the webinar provided instruction for using:
Patient Safety and Quality Improvement Act (PSQIA) protections in Medicare Shared Savings Programs, centralized peer review programs, and other collaboratives.
PSQIA protections for new types of clinical analysis, clinical quality reports, and performance tools that contain information that may not be protected under existing state peer review privilege or are shared among an integrated network.
How a Real-Time Automated Decision-Support Tool Can Cure the Prior Authorizat...Cognizant
A collaboration between Cognizant, the New England Healthcare Exchange Network and Informatics In Context is demonstrating how a real-time prior authorization (PA) system for medical and administrative processes saves time and money.
White Paper - eCQMs: It's Time to Make Data Quality the No. 1 Priority Q-Centrix
This white paper will examine eCQM data quality issues and their implications. It will raise questions hospitals should consider when developing strategies to improve their eCQM capabilities. Lastly, it will outline how they can benefit from implementing better data quality control practices and present new developments in eCQM data collection and reporting.
PYA Highlights Next Steps of Meaningful UsePYA, P.C.
At the 2013 AICPA Healthcare Industry Conference, PYA Principal David McMillan and Senior Manager Chris Wilson recently explored the “new normal” of meaningful use as compliance and strategic standards in new care/reimbursement-model development.
NCQA’s Accreditation process provides payers with a comprehensive framework to improve quality of care and services. It allows members and employers to compare health plan performance across various plans and against industry benchmarks. NCQA accreditation has 3 parts – HEDIS, Patient experience CAHPS measures and NCQA standards
Current Trends in Data Protection for Integrated Health, Centralized Peer Rev...PYA, P.C.
A webinar hosted by PYA and the Alliance for Quality Improvement (AQIPS) explored “Current Trends in Data Protection for Integrated Health, Centralized Peer Review Systems, and Other Innovative Programs.” PYA Principal Martie Ross participated in the webinar, which focused on how patient safety organization (PSO) protections can bring value to accountable care organizations and other integrated health systems.
In addition, the webinar provided instruction for using:
Patient Safety and Quality Improvement Act (PSQIA) protections in Medicare Shared Savings Programs, centralized peer review programs, and other collaboratives.
PSQIA protections for new types of clinical analysis, clinical quality reports, and performance tools that contain information that may not be protected under existing state peer review privilege or are shared among an integrated network.
Fighting FWA in the Payer Industry Using Big DataCitiusTech
This document gives a brief introduction on Fraud, Waste and Abuse (FWA) and lists down traditional as well as modern FWA challenges. It also gives an introduction to Big Data analytics and how it can be used to solve these challenges. Readers will have a better understanding on why and how Big Data should be used to identify occurrences and patterns of FWA in Payer industry.
Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse...PYA, P.C.
PYA Senior Manager Chris Beckham co-presented “Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny” with Ross Burris of Polsinelli at the American Health Lawyer Association’s (AHLA) Physicians and Hospitals Law Institute, February 8-10, 2016.
This 17-page document will inspire and guide you through WHY it's time to re-consider your agency technology. Furthermore, this guide will help you answer WHAT you need to know about the shifting home healthcare landscape from a traditional Fee-for-Service model to outcome/bundled reimbursement.
With this guide, you'll learn about topics such as:
1. What is the Bundled Payment Model?
2. Why Home Health Care Agencies Require Technology
3. Steps to Buying a Software Solution
4. Key Factors and Features to Keep in Mind
What do big data and advanced analytics mean for healthcare? This question was answered during the Georgia Society of CPAs (GSCPA) 2015 Healthcare Conference, February 6, at the Cobb Galleria Centre in Atlanta, GA. PYA Principal Marty Brown and PYA Analytics President & CEO Brian Worley presented “Big Data Applications in Healthcare.”
Quality and Outcome Framework (QOF) is a voluntary annual incentive programme for GPs in England, detailing practice achievement results. The primary objective of QOF is to drive the quality of primary care and reduce variations in the quality of care amongst GPs
The Evolving Role of the Compliance Officer in the Age of Accountable CarePYA, P.C.
Much has been written about new competencies physicians must develop in the face of payment and delivery system reform. But providers are not the only ones seeing their roles change. Compliance officers, who serve as organizations’ internal police officers, will have many new challenges. PYA Principal Martie Ross presented a national Health Care Compliance Association (HCCA) webinar entitled “The Evolving Role of the Compliance Officer In the Age of Accountable Care.”
Driving Home Health Efficiency through Data AnalyticsCitiusTech
This whitepaper highlights how data analytics can help track key performance indicators to drive clinical, financial and operational efficiency to improve quality of home health in an efficient manner.
The healthcare transformation from fee for service to fee for outcomes just got an adrenaline shot in the arm April 27th when the Department of Health and Human Services surprised many in the market by announcing a Quality Payment Program, a proposed set of new rules to take effect in 2019 based on key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
The Future of RCM in Healthcare OrganizationsCitiusTech
This document / whitepaper talks about how healthcare technology companies can leverage emerging technologies to derive insights to improve their Revenue Cycle Management process.
RPA (Robotic Process Automation) promises to automate various complex tasks for healthcare organizations – payers and providers – to improve member experience, lower costs and relieve employees from rising pressure of work. But when it comes to actual applications of RPA, most companies are having a difficult time. This brief eBook outlines the benefits, challenges, tools and key healthcare use cases of RPA that can help healthcare organizations boost their productivity.
In this live webinar, Valora outlines the three main stages of starting a medical practice:
1) Planning - creating a business plan, setting a budget and outlining your timeline
2) The Nuts and Bolts - finding a location, credentialing, administrative setup, and choosing the right technology for your needs
3) Opening - hiring staff and activating your marketing plans
PYA Principal Carol Carden presented “Fundamentals of Healthcare Valuation” at the American Society of Appraisers (ASA) 2015 Advanced Business Valuation Conference. The presentation explored unique characteristics of the healthcare industry, particularly those relevant to appraisers for avoiding common mistakes in assessing risk and projecting cash flow.
HIPAA & OIG Compliance for Medical Billing Company OwnersKareo
The success of your business relies on timely billing and accurate coding. Whether you’re managing the billing for one provider or 50, it’s a complex job that must meet a variety of regulations, making it easy for medical billing companies to be the target of false claims and fraudulent crimes. As healthcare fraud continues to be a growing issue in the industry, medical billers are increasingly being held liable for their role in the submission of fraudulent claims.
Executive Director of American Medical Billing Association, Cyndee Weston, CMRS, CMCS, CPC, will provide an in-depth analysis of what can be considered fraud when submitting medical claims, how the government is enforcing guidelines, and what you can do to help protect your business as well as your practices.
Private Practice Model Perspectives 2015 SurveyKareo
Kareo believes in the independent practice and the physician entrepreneur. Small practices are vital to their communities for the personalized care they can offer; however, to keep the doors of a small practice open, healthcare providers need to learn to think like an entrepreneur to ensure financial stability and improved patient satisfaction. And there’s never been a better time to be a physician entrepreneur in healthcare.
The demand for individualized care and convenience has become exceedingly important to patients as they are coming to expect the same level of service from their provider as they receive in other aspects of their lives. With the average deductible exceeding $1,200 and roughly 80 percent of employers offering high deductible plans in 2015, patients are beginning to think more like consumers. This new demand is a crucial piece for healthcare providers who own a private practice, as they are better positioned to handle this demand than larger healthcare systems. In short, the trend towards the consumerization of healthcare favors the small practice over large healthcare organizations.
To empower the small practice physician, Kareo is shining a light on the path to success—an agile medical practice model—combining traditional fee for service options with the flexibility of concierge services. This includes offering flexible payment plans and increasing the focus on practice marketing and patient engagement.
The convergence of health plans and healthcare providers has led to the growing importance for provider-led health plans (Payviders). This eBook highlights the data and technology capabilities necessary for Payvider organizations to optimize performance and drive operational efficiencies.
21st Century Act and its Impact on Healthcare ITCitiusTech
This document gives an overview, core objectives of the act and enumerates purpose of each part / division of the 21st Century Act. It lists down the sections of the act which have a direct impact on Healthcare IT and gives a brief overview of each section.This document also explains the impact of 21st Century Cures Act on regulatory bodies: FDA / NIH / HSS.
How Decision-Support Tools Cure the Prior Authorization Time DrainCognizant
A collaboration between Cognizant, the New England Healthcare Exchange Network and Informatics In Context is demonstrating how a real-time prior authorization (PA) system for medical and administrative processes saves time and money.
Fighting FWA in the Payer Industry Using Big DataCitiusTech
This document gives a brief introduction on Fraud, Waste and Abuse (FWA) and lists down traditional as well as modern FWA challenges. It also gives an introduction to Big Data analytics and how it can be used to solve these challenges. Readers will have a better understanding on why and how Big Data should be used to identify occurrences and patterns of FWA in Payer industry.
Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse...PYA, P.C.
PYA Senior Manager Chris Beckham co-presented “Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny” with Ross Burris of Polsinelli at the American Health Lawyer Association’s (AHLA) Physicians and Hospitals Law Institute, February 8-10, 2016.
This 17-page document will inspire and guide you through WHY it's time to re-consider your agency technology. Furthermore, this guide will help you answer WHAT you need to know about the shifting home healthcare landscape from a traditional Fee-for-Service model to outcome/bundled reimbursement.
With this guide, you'll learn about topics such as:
1. What is the Bundled Payment Model?
2. Why Home Health Care Agencies Require Technology
3. Steps to Buying a Software Solution
4. Key Factors and Features to Keep in Mind
What do big data and advanced analytics mean for healthcare? This question was answered during the Georgia Society of CPAs (GSCPA) 2015 Healthcare Conference, February 6, at the Cobb Galleria Centre in Atlanta, GA. PYA Principal Marty Brown and PYA Analytics President & CEO Brian Worley presented “Big Data Applications in Healthcare.”
Quality and Outcome Framework (QOF) is a voluntary annual incentive programme for GPs in England, detailing practice achievement results. The primary objective of QOF is to drive the quality of primary care and reduce variations in the quality of care amongst GPs
The Evolving Role of the Compliance Officer in the Age of Accountable CarePYA, P.C.
Much has been written about new competencies physicians must develop in the face of payment and delivery system reform. But providers are not the only ones seeing their roles change. Compliance officers, who serve as organizations’ internal police officers, will have many new challenges. PYA Principal Martie Ross presented a national Health Care Compliance Association (HCCA) webinar entitled “The Evolving Role of the Compliance Officer In the Age of Accountable Care.”
Driving Home Health Efficiency through Data AnalyticsCitiusTech
This whitepaper highlights how data analytics can help track key performance indicators to drive clinical, financial and operational efficiency to improve quality of home health in an efficient manner.
The healthcare transformation from fee for service to fee for outcomes just got an adrenaline shot in the arm April 27th when the Department of Health and Human Services surprised many in the market by announcing a Quality Payment Program, a proposed set of new rules to take effect in 2019 based on key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
The Future of RCM in Healthcare OrganizationsCitiusTech
This document / whitepaper talks about how healthcare technology companies can leverage emerging technologies to derive insights to improve their Revenue Cycle Management process.
RPA (Robotic Process Automation) promises to automate various complex tasks for healthcare organizations – payers and providers – to improve member experience, lower costs and relieve employees from rising pressure of work. But when it comes to actual applications of RPA, most companies are having a difficult time. This brief eBook outlines the benefits, challenges, tools and key healthcare use cases of RPA that can help healthcare organizations boost their productivity.
In this live webinar, Valora outlines the three main stages of starting a medical practice:
1) Planning - creating a business plan, setting a budget and outlining your timeline
2) The Nuts and Bolts - finding a location, credentialing, administrative setup, and choosing the right technology for your needs
3) Opening - hiring staff and activating your marketing plans
PYA Principal Carol Carden presented “Fundamentals of Healthcare Valuation” at the American Society of Appraisers (ASA) 2015 Advanced Business Valuation Conference. The presentation explored unique characteristics of the healthcare industry, particularly those relevant to appraisers for avoiding common mistakes in assessing risk and projecting cash flow.
HIPAA & OIG Compliance for Medical Billing Company OwnersKareo
The success of your business relies on timely billing and accurate coding. Whether you’re managing the billing for one provider or 50, it’s a complex job that must meet a variety of regulations, making it easy for medical billing companies to be the target of false claims and fraudulent crimes. As healthcare fraud continues to be a growing issue in the industry, medical billers are increasingly being held liable for their role in the submission of fraudulent claims.
Executive Director of American Medical Billing Association, Cyndee Weston, CMRS, CMCS, CPC, will provide an in-depth analysis of what can be considered fraud when submitting medical claims, how the government is enforcing guidelines, and what you can do to help protect your business as well as your practices.
Private Practice Model Perspectives 2015 SurveyKareo
Kareo believes in the independent practice and the physician entrepreneur. Small practices are vital to their communities for the personalized care they can offer; however, to keep the doors of a small practice open, healthcare providers need to learn to think like an entrepreneur to ensure financial stability and improved patient satisfaction. And there’s never been a better time to be a physician entrepreneur in healthcare.
The demand for individualized care and convenience has become exceedingly important to patients as they are coming to expect the same level of service from their provider as they receive in other aspects of their lives. With the average deductible exceeding $1,200 and roughly 80 percent of employers offering high deductible plans in 2015, patients are beginning to think more like consumers. This new demand is a crucial piece for healthcare providers who own a private practice, as they are better positioned to handle this demand than larger healthcare systems. In short, the trend towards the consumerization of healthcare favors the small practice over large healthcare organizations.
To empower the small practice physician, Kareo is shining a light on the path to success—an agile medical practice model—combining traditional fee for service options with the flexibility of concierge services. This includes offering flexible payment plans and increasing the focus on practice marketing and patient engagement.
The convergence of health plans and healthcare providers has led to the growing importance for provider-led health plans (Payviders). This eBook highlights the data and technology capabilities necessary for Payvider organizations to optimize performance and drive operational efficiencies.
21st Century Act and its Impact on Healthcare ITCitiusTech
This document gives an overview, core objectives of the act and enumerates purpose of each part / division of the 21st Century Act. It lists down the sections of the act which have a direct impact on Healthcare IT and gives a brief overview of each section.This document also explains the impact of 21st Century Cures Act on regulatory bodies: FDA / NIH / HSS.
How Decision-Support Tools Cure the Prior Authorization Time DrainCognizant
A collaboration between Cognizant, the New England Healthcare Exchange Network and Informatics In Context is demonstrating how a real-time prior authorization (PA) system for medical and administrative processes saves time and money.
329
Mini-Case Study 4:
Technology in Health Care:
Automating Admissions
P rocesses*
Eric Christ
29
C H A P T E R
Alexander Bain was a clever fellow. He invented the electric clock and the first electric
printing telegraph. He also invented the fax machine, the device that many long-term care
providers rely on for patient referral and admissions communications. That was in 1843.
That’s right; the technology at the core of the referral and admissions process for many
continuing care providers is more than 150 years old.
Needless to say, a lot has changed since then. Providers can benefit from these changes
by looking at their patient intake processes and considering ways to use the Internet and
other technological advances to automate and accelerate admissions and referral
management.
ASSESS ADMISSIONS PROCESS
The first step for providers who are considering improved tools for patient intake is to assess
current processes. Here are some good questions to start with:
• How many referrals are received per day or per month?
• How many sources (hospitals, physicians, liaisons, other long-term care providers)
send referrals?
• How many pages of documents are associated with each referral?
• How are patient review and approval tasks assigned and tracked?
• How are referral and intake activities collected and reported?
Many providers do not realize what vast mountains of paper they manage. Results from
a 2007 survey of about 400 skilled nursing facilities and home health agencies indicate the
average provider receives four referrals per day, each with 22 pages of related documents.
That’s 1,460 referrals and 32,120 pages of documents per year—an eight-foot stack of paper
for the average provider to process, review, and manage.
In a study conducted by a Canadian health policy organization, nursing facility admis-
sions processes were found to involve 160 steps, including 69 handling steps, 36 forms to
*E. Christ, “Technology in Health Care: Automating Admissions Processes,” Provider Magazine (Oct. 2008):
81–84. Reprinted with permission from Provider Magazine.
330 CHAPTER 28 Mini-Case Study 4: Technology in Health Care
complete, four family trips to the facility that involved 53 steps and five staff members, and
nine forms.
AREAS TO AUTOMATE
Clearly, providers have many opportunities to streamline the admissions process. For ex-
ample, there are typically four to five steps between an initial inquiry and a response to
the referral source, after which insurance must be verified before a final decision to admit
is made.
Once a provider has identified the steps in its admissions process, it can evaluate ways to
apply messaging, management, and workflow technologies that can improve admissions in
the following areas: fax and document management, communications, referral tracking
and approval, and reporting.
FAX AND DOCUMENT MANAGEMENT
“Any solution that doesn’t address the fax challenges will typically fall short,” says Felicia
Wil.
The most expensive and time-consuming prior authorization process is simplified using robotic process automation. Hospitals and health systems are successful in implementing RPA.
Provide transparent treatment costs, benefits and limitations by leveraging RPA bots verification process, giving access to doctors so that their patients can be educated during visits of upcoming costs according to no surprise act.
Recent reports indicate that physicians are stressed and overburdened by several administrative challenges, leaving them with less time for patient care.
Get Best Credentialing Software | Clinic Spectrum.pdfJackHall26
Credentialing Spectrum is a safe, cloud-based medical credentialing platform for facility, payer, and contract administration. It is software for healthcare credentialing that aims to improve efficiency and streamline the procedure. Credentialing Spectrum is a one-click full automation system and is the best provider credentialing software currently available in the USA. Contact us by going to Clinic Spectrum straight away.
Website- https://www.clinicspectrum.com/CredentialingSpectrum
Clinic Spectrum - Best Credentialing Software Provider JackHall26
Credentialing Spectrum is a secure, cloud-based medical credentialing software for facility, payer, and contract administration. It is software for healthcare credentialing that aims to improve productivity and streamline procedures. The best credentialing software provider in the USA is Credentialing Spectrum, which has a one-click complete automation solution that makes it convenient.
Website- https://www.clinicspectrum.com/CredentialingSpectrum
What hospitals need to do to increase referral profitability?GaryRichards30
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.
Operations in hospitals including RCM processes, patient data collection, data validation and internal audits efficiency increased by Robotic process automation (RPA).
Hospital Management and Inventory Control Solution for Public Hospitals in De...Mamoon Ismail Khalid
Historic underinvestment in public health has left Ecuador
with one of the most inefficient health systems in the region.
The Problem
Little info sharing
The lack of interoperable
systems and records
management contributes to a
lack of understanding of public
health needs leads to
treatments that don't really
address overall health issues
Bureaucracy
Public health employees are
engaged in redundant
administrative tasks that divert
resources from patient care and
clog system
PAPER RECORDING OF INFORMATION
Medical assistants need to manually fill in 5
different records (1 per prescription), they
first do it in paper and then typed it in the
computer since the Wi-Fi is not reliable.
Excessive waits
Lead times for getting
appointments in and long
check in processes lead to
patients abandoning
preventative care that could
save money and improve
patient outcomes
Most people we surveyed
complained about lead time. It
becomes even more
aggravating when it’s an
emergency.
Abuse and waste
Inability to track prescriptions
and inventory offer opportunity
for abuse that undermines the
system's overall quality
The result:
Costly, Inefficient
and non-citizen
centric public
healthcare system
The result:
Costly, Inefficient
and non-citizen
centric public
healthcare system
Outpatient RCM operations such as medical billing, coding, AR, and denial management are tedious from various aspects. Some of the problem areas such as in-house RCM team hiring, and maintaining those staff under the limited budget, and lack of experience in the practice's specialty all are reasons for Outpatient RCM services Outsourcing by 22% of RCM Leaders. RCM leaders like CFOs, CEOs, RCM directors, and VPs tend to outsource most of the RCM operations to third-party companies so that they can concentrate more on the clinical staff hiring, administration, and the primary core function of all excellent patient care.
Are Electronic Medical Records a Cure for Health CareCASE STU.docxrossskuddershamus
Are Electronic Medical Records a Cure for Health Care?
CASE STUDY #1
During a typical trip to the doctor, you’ll often see shelves full of folders and papers devoted to the storage of medical records. Every time you visit, your records are created or modified, and often duplicate copies are generated throughout the course of a visit to the doctor or a hospital. The majority of medical records are currently paper-based, making these records very difficult to access and share. It has been said that the U.S. health care industry is the world’s most inefficient information enterprise. Inefficiencies in medical record keeping are one reason why health care costs in the United States are the highest in the world. In 2012, health care costs reached $2.8 trillion, representing 18 percent of the U.S. gross domestic product (GDP). Left unchecked, by 2037, health care costs will rise to 25 percent of GDP and consume approximately 40 percent of total federal spending. Since administrative costs and medical recordkeeping account for nearly 13 percent of U.S health care spending, improving medical record keeping systems has been targeted as a major path to cost savings and even higher quality health care. Enter electronic medical record (EMR) systems.
An electronic medical record system contains all of a person’s vital medical data, including personal information, a full medical history, test results, diagnoses, treatments, prescription medications, and the effect of those treatments. A physician would be able to immediately and directly access needed information from the EMR without having to pore through paper files. If the record holder went to the hospital, the records and results of any tests performed at that point would be immediately available online. Having a complete set of patient information at their finger-tips would help physicians prevent prescription drug interactions and avoid redundant tests. By analyzing data extracted from electronic patient records, Southeast Texas Medical Associates in Beaumont, Texas, improved patient care, reduced complications, and slashed its hospital readmission rate by 22 percent in 2010.
Many experts believe that electronic records will reduce medical errors and improve care, create less paperwork, and provide quicker service, all of which will lead to dramatic savings in the future, as much as $80 billion per year. The U.S. government’s short-term goal is for all health care providers in the United States to have EMR systems in place that meet a set of basic functional criteria by the year 2015. Its long-term goal is to have a fully functional nationwide electronic medical recordkeeping network. The consulting firm Accenture estimated that approximately 50 percent of U.S. hospitals are at risk of incurring penalties by 2015 for failing to meet federal requirements.
Evidence of EMR systems in use today suggests that these benefits are legitimate. But the challenges of setting up individual systems, let alo.
Using Adaptive Scrum to Tame Process Reverse Engineering in Data Analytics Pr...Cognizant
Organizations rely on analytics to make intelligent decisions and improve business performance, which sometimes requires reproducing business processes from a legacy application to a digital-native state to reduce the functional, technical and operational debts. Adaptive Scrum can reduce the complexity of the reproduction process iteratively as well as provide transparency in data analytics porojects.
It Takes an Ecosystem: How Technology Companies Deliver Exceptional ExperiencesCognizant
Experience is evolving into a strategy that reaches across technology companies. We offer guidance on the rise of experience and its role in business modernization, with details on how orgnizations can build the ecosystem to support it.
The Work Ahead: Transportation and Logistics Delivering on the Digital-Physic...Cognizant
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The Work Ahead in Manufacturing: Fulfilling the Agility MandateCognizant
According to our research, manufacturers are well ahead of other industries in their IoT deployments but need to marshal the investment required to meet today’s intensified demands for business resilience.
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Higher-ed institutions expect pandemic-driven disruption to continue, especially as hyperconnectivity, analytics and AI drive personalized education models over the lifetime of the learner, according to our recent research.
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In recent years, insurers have invested in technology platforms and process improvements to improve
claims outcomes. Leaders will build on this foundation across the claims landscape, spanning experience,
operations, customer service and the overall supply chain with market-differentiating capabilities to
achieve sustainable results.
Profitability in the Direct-to-Consumer Marketplace: A Playbook for Media and...Cognizant
Amid constant change, industry leaders need an upgraded IT infrastructure capable of adapting to audience expectations while proactively anticipating ever-evolving business requirements.
Green Rush: The Economic Imperative for SustainabilityCognizant
Green business is good business, according to our recent research, whether for companies monetizing tech tools used for sustainability or for those that see the impact of these initiatives on business goals.
Policy Administration Modernization: Four Paths for InsurersCognizant
The pivot to digital is fraught with numerous obstacles but with proper planning and execution, legacy carriers can update their core systems and keep pace with the competition, while proactively addressing customer needs.
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Utilities are starting to adopt digital technologies to eliminate slow processes, elevate customer experience and boost sustainability, according to our recent study.
AI in Media & Entertainment: Starting the Journey to ValueCognizant
Up to now, the global media & entertainment industry (M&E) has been lagging most other sectors in its adoption of artificial intelligence (AI). But our research shows that M&E companies are set to close the gap over the coming three years, as they ramp up their investments in AI and reap rising returns. The first steps? Getting a firm grip on data – the foundation of any successful AI strategy – and balancing technology spend with investments in AI skills.
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As #WorkFromAnywhere becomes the rule rather than the exception, organizations face an important question: How can they increase their digital quotient to engage and enable a remote operations workforce to work collaboratively to deliver onclient requirements and contractual commitments?
Five Priorities for Quality Engineering When Taking Banking to the CloudCognizant
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The Work Ahead in Intelligent Automation: Coping with Complexity in a Post-Pa...Cognizant
Intelligent automation continues to be a top driver of the future of work, according to our recent study. To reap the full advantages, businesses need to move from isolated to widespread deployment.
The Work Ahead in Intelligent Automation: Coping with Complexity in a Post-Pa...
Automated Prior Authorization: A High-Value Opportunity
1. Digital Operations
Automated Prior Authorization:
A High-Value Opportunity
InthefaceofmanualPAproliferationandpressurefromthevalue-basedcare
model,theneedisgrowingforreal-timeelectronicPAsystemsthatwilleasethe
administrativeburdenonstakeholdersthroughoutthehealthcareecosystem.
Executive Summary
Though prior authorization (PA) is an important tool
for controlling the rising cost of U.S. healthcare, it also
represents a common pain point for both payers and
providers in terms of cost and administrative burden.
These burdens can also act contrary to organizations
moving toward value-based care and a consumer-
centric healthcare system. Electronic and automated
PA systems can lower the costs and burdens of the PA
process for all parties, but not all solutions are created
equal or deployed effectively. To identify and understand
current and future trends, obstacles and opportunities in
PA, Leavitt Partners conducted a series of interviews with
medical and pharmacy directors from payers, including
health plans and pharmacy benefit managers (PBMs),
across the U.S. regarding their PA process, challenges
and best practices.
Cognizant 20-20 Insights
May 2019
2. For large providers, it’s possible to achieve an effective PA
process, but only with a lot of dedicated manpower, a specialized
team, and a relatively high level of investment. Smaller
organizations would find it much more difficult to develop the
needed staff and expertise to interact with all the payer systems
in a timely manner for patients.
ww Interviewee
The administrative and cost burden of PA
As healthcare costs have continued to rise, payers
are increasingly focusing on PA as a utilization
management tool. The percentage of medical
claims referencing PA increased on average by
2.3% from 2011 to 2013, with some payers doubling
and tripling the number of care events that require
authorization.1
These statistics do not include
pharmaceutical PAs, so the number is most likely
much higher when factored in.
Eighty-six percent of physicians report that the
burden of PAs has increased over the past five
years. One study estimated that on average, PA
requests consumed about 20 hours a week per
medical practice: one hour of the doctor’s time,
nearly six hours of clerical time, plus 13 hours of
nurses’ time.2
On the payer side, PA systems can
require a substantial investment both in the initial
development of a system and in human capital to
have qualified experts review and make decisions
on PA submissions.
PA costs quickly compound into a significant
burden. One study estimated that when time is
converted to dollars, practices spent an average
of $68,274 per physician per year for interacting
with health plans. This equates to between $23
billion and $31 billion annually.3
About one-third
of doctors are using dedicated data-entry staff to
handle PA requests, which incurs an extra cost;
for the other two thirds of doctors, the PA process
reduces the time available to see patients.4
Care
interruptions caused by PA delays are also costly.
A cancelled appointment or procedure due to a
missing or denied PA results in lost revenue, and
expensive staff and equipment sit unused.
Cognizant 20-20 Insights
2 / Automated Prior Authorization: A High-Value Opportunity
3. Cognizant 20-20 Insights
3 / Automated Prior Authorization: A High-Value Opportunity
The opportunity cost of electronic PA
The high cost burden of PAs presents an equally
large opportunity. A 2018 study found that
electronic PA could save as much as 416 hours
per year for a physician and his or her staff.5
Additional research estimated that the average
cost to a provider for a fully electronic PA was
$1.89, compared to $7.50 for an entirely manual
authorization.6
PAs with attachments have shown
a high savings opportunity per transaction, with
savings estimates upward of $45 per transaction.7
In one report, providers that exclusively used
electronic PAs for medication requests reduced
their administrative workload by 2.5 hours each
week. Modernizing the system can lower cost
not only in terms of manpower and time, but also
through other considerations like devices, space or
toner usage over the long term.
But for some, the move to electronic PA systems
has yet to result in significant cost savings and/or
personnel reduction. Many interviewees seemed
to fall into a dissatisfactory “middle ground” of
investing in an expensive, and sometimes unwieldy,
electronic solution that had not yet resulted in
being able to relieve staff due to automation.
Several interviewees reported having to increase
the size of their PA teams in recent years despite
the introduction of electronic tools, saying that
the tools hadn’t become sophisticated or tailored
enough to save time or personnel. Additionally,
several interviewees reported that PA/electronic
health record (EHR) systems often remain
incompatible, so providers must manually pull the
necessary records to submit as part of a PA.
We have seen a high
level of success with a
highly automated PA
system based on clinical
pathways, and we’ve been
able to pass the savings
from this system on to
consumers in the form of
lower premiums, enabling
us to stay competitive in
our market.
ww Interviewee
4. Cognizant 20-20 Insights
4 / Automated Prior Authorization: A High-Value Opportunity
Lack of agreement about what is possible in terms of PA
Currently, the vast majority of payers (96%)
are committed to implementing electronic PA
solutions as a way to address administrative
problems with procedures.8
But actual adoption
of electronic systems has lagged far behind other
transaction types, as the percentage of plans and
providers that use fully electronic systems remains
in the single digits (see Figure 1). Over one third
of PA systems are still fully manual.9
The variance
across systems compounds this problem – 76% of
providers report working with a combination of fax,
phone and electronic channels.10
There is a lack of
industry consensus around what is even possible in
terms of a real-time automated PA solution.
Quotes from three interviewees illustrate the
broad difference of opinions among payers:
Payer A
“A fully electronic system with
no delay is the ideal, but it
doesn’t exist and may not be
developed within the next 10
years.”
Payer B
“The technological capability
for an effective PA system
may exist, but someone needs
to invest in customizing and
maintaining it.”
Payer C
“An ideal-state PA system is
achievable – we try and often
succeed to have all necessary
PAs completed before our
patients leave the office.”
Adoption of Electronic PA by Medical Plans and Providers
Figure 1
Source: 2017 CAQH Index
56%
7%
38%
58%
10%
32%
47%
19%
35%
57%
8%
35%
FULLY ELECTRONIC PARTIALLY ELECTRONIC FULLY MANUAL
2014 2015 2016 2017
Further, all interviewees wanted a more automated
system, but many expressed concern that critical
decision-making is needed for patients who might
have a complex case or be exceptions to the rule.
They worried that a fully automated system would
see these patients slip through the cracks.
5. Cognizant 20-20 Insights
5 / Automated Prior Authorization: A High-Value Opportunity
The potential of automation
A transition to automation presents new
opportunities. Though electronic solutions have
proved they can save significant time and money,
even processes that use electronic aspects often
include manual components either on the provider
or payer end, especially with many diverse and
non-interoperable systems. For example, some
providers send PAs manually to a clearinghouse or
another partner that then converts these records
to an electronic format for the payer. Conversely, a
provider may have to manually submit information
using a payer web portal; while the process is
“electronic” on the payer end, the transaction still
takes time and resources for manual input on the
provider end. These manual inputs can create
bottlenecks that leave PAs taking days to process.
Automated PAs would use a solution that
automatically matches the request to parameters
set by the payer to ensure accuracy. Once
eligibility, benefits design and clinical guidelines
are met, the authorization can be instantly
adjudicated and returned to the provider while
the patient is still in office. Those requests that
contain errors or do not conform to payer rules
would be flagged and returned to the provider just
as quickly for correction. Effectively leveraging
the power of real-time automation can be a key
solution for payers and providers who feel they are
investing in electronic PA systems without seeing
a high enough ROI, as well as opening the current
bottleneck of care for patients.
6. Cognizant 20-20 Insights
6 / Automated Prior Authorization: A High-Value Opportunity
The responsibility of making PA work for patients
The statistics on PA turnaround time can be
staggering and have real implications for effective
care delivery:
❙❙ 64% of physicians report that they have waited at
least one business day for a PA decision and 30%
say they have waited three or more business days.
❙❙ 79% of providers report that they are sometimes,
often or always required to repeat PAs.
❙❙ 92% of physicians say that PA programs have a
negative impact on patient clinical outcomes.
❙❙ Patients often become discouraged by the PA
process, with 78% of doctors reporting that
PA can at least sometimes lead the patient to
abandon treatment.11
These challenges can interfere with provider care
plans, especially as physicians might not immediately
know that a delay has occurred. For example, a
consumer may be prescribed a medicine and
expect to be able to enter the pharmacy and pick
it up right away, only to discover that a PA was not
yet approved. Patients can become confused and
frustrated with their payer, pharmacist and physician.
The PA process and its associated delays present
significant problems for pharmacists and patients.
The majority of prescriptions (66%) rejected at
the pharmacy require PAs, amounting to about
300 million PA requests per year.12
Of those
prescriptions, 36% are abandoned. Resolving
PAs can cost pharmacists just as much time as
physicians, and many patients will associate that
delay with the pharmacist, while the pharmacist
feels the issue rests with the payer. One interviewee,
a director at a specialty pharmacy, reported that it
typically takes one to three days to get a PA, which
in her view is most often an unnecessary delay. The
high volume of PAs processed by her pharmacy
has allowed her to determine with relative certainty
which PAs are merely a formality (i.e., approval is
almost always given) and which are clinically justified.
Patient Impact of PA
Figure 2
Source: CoverMyMeds Analytics
About 1 in 10 prescription claims are rejected at the pharmacy.
66%
of rejected
prescriptions
require PA.
33%
of these will be
abandoned by
the patient.
7. Net promoter score is critical, and physician satisfaction is
hugely important to the net promoter score. A PA system that
providers are happy with affects that a great deal. Net promoter
score is also linked to a patient’s relationship with their doctor,
so when care is more seamless, scores go up.
ww Interviewee
Cognizant 20-20 Insights
7 / Automated Prior Authorization: A High-Value Opportunity
This implies that an automated PA system could
significantly reduce the time burden for patients
and the cost burden for providers by drastically
decreasing PA turnaround time. This would also
result in increased patient satisfaction and better
medication adherence.
While parties agree that PAs take too long,
payers and providers often disagree on whose
responsibility it is to tackle this problem. Some
payers prefer to rely on the “sentinel” effect of PAs
to avoid delays – expecting physicians to learn the
medication formularies or clinical guidelines for all
the payers they work with and avoid prescribing
drugs or procedures they know to be PA-
dependent. Physicians may not regard this as their
responsibility, and they feel that payers should be
accountable for creating an efficient PA system so
their members do not experience care delays.
At the bottom line, an effective PA system requires
buy-in on both sides of the equation. While it can
be difficult to make changes to an entrenched
PA system, doing so can improve payer-provider
synergies. An ideal-state PA solution requires an
initial investment on the part of payers, but over
time it can broker trust with physicians by limiting
their administrative burden and helping to ensure
that their patients’ well-being is a priority.
8. Cognizant 20-20 Insights
8 / Automated Prior Authorization: A High-Value Opportunity
PA and the transition to value
The growing shift to value-based care is driving
demand for improved PA tools and processes.
Value-based care introduces more financial stress
for providers,13
and a PA system causing care
delays that interrupt clinical pathways affects a
patient’s satisfaction with their provider, or affects
patient adherence to treatment guidelines that
can present a risk for organizations participating in
value-based care.14
When flaws in the PA system
have detrimental effects on patient care, this affects
quality outcomes that are important to value-based
contracting. A truly effective PA system can help
value-based care and PAs work to achieve similar
goals of cutting cost and eliminating unnecessary
utilization while maintaining positive health
outcomes. Interviewees agreed that the more
satisfied providers are with their PA system, the
more likely they are to change their behavior over
time based on PA feedback, rather than consider
PAs as a flawed system or a barrier to effective care.
One pharmacy director at a regional, provider-
owned health system reported that risk-bearing
entities tend to have a significantly lower number of
PA denials despite having seemingly similar systems
and decision-making processes. The interviewee
suggested that the decrease in both PA requests
and denials from value-based organizations can be
attributed to incentives that encourage doctors to
avoid using PAs altogether. These incentives may
9. Cognizant 20-20 Insights
9 / Automated Prior Authorization: A High-Value Opportunity
align with explicit organizational mandates (e.g.,
prescribing cheaper drugs where possible to save
money), but may also be the result of physicians’
desire to avoid the added expense and hassle of
the PA process for which they receive no additional
compensation.
The ongoing transition to value will present
opportunities for payers and providers who are
looking to mutually improve the PA process and
align incentives and risks. A 2018 Consensus
Statement by the AMA, AHA, AHIP and other
organizations stated that while PA can help to
maximize the value of healthcare spending,
improving the process is critical for patients
and doctors. The statement recommended
that healthcare leaders “reduce the number
of healthcare professionals subject to prior
authorization requirements based on their
performance, adherence to evidence-based
medical practices, or participation in a value-based
agreement with the health insurance provider.”15
Physicians who are willing to participate in
agreements where they are held accountable for
cost and performance will likely welcome reform to a
PA process that supports them in these goals.
10. Cognizant 20-20 Insights
10 / Automated Prior Authorization: A High-Value Opportunity
Looking ahead
PA is poised to undergo a major transformation
as both payers and providers struggle to fully
make the switch to electronic models. As PAs will
continue to be an important cost-containment
tool for payers and plan sponsors, the importance
of a system that works for today’s providers
and patients only grows. Value-based care
arrangements and rapidly developing health
information technologies will also drive motivation
and capability to make the change.
There is a key opportunity for payers and providers
to reduce administrative and cost burden through
the implementation of electronic and automated
solutions. As accountability for patient outcomes
and costs becomes increasingly important across
healthcare stakeholders, an effective PA system can
also play a role in bringing value to the point of care.
A real-time automated solution has the potential
to tackle administrative and clinical requirements,
increase payer-provider cooperation and ensure
that patients get the proper care when they need it.
11. Cognizant 20-20 Insights
11 / Automated Prior Authorization: A High-Value Opportunity
Endnotes
1 Bricker, Eric, “Healthcare Insurance Carriers Requiring Prior Authorization: Stats and Trends,” Compass, 2013, https://alight.
com/compass.
2 Casalino, Lawrence, et al., “What Does It Cost Physician Practices to Interact With Health Plans?” Health Affairs, July/August,
www.healthaffairs.org/doi/full/10.1377/hlthaff.28.4.w533.
3 Ibid.
4 “Survey: Patient clinical outcomes shortchanged by prior authorization,” American Medical Association, March 19, 2018,
www.ama-assn.org/survey-patient-clinical-outcomes-shortchanged-prior-authorization.
5 Mendelowitz, Josh, “What’s Wrong with Prior Authorization for Medication and How to Fix It,” Healthcare.com, Aug. 28,
2018, www.healthcare.com/blog/how-fix-prior-authorization-medication/.
6 Mattson-Hamilton, Michelle, “A review of electronic prior authorization technology,” TechTarget, June 9, 2017,
https://searchhealthit.techtarget.com/feature/A-review-of-electronic-prior-authorization-technology.
7 “2015 CAQH Index,” Council for Affordable Quality Healthcare, March 12, 2015, www.caqh.org/sites/default/files/
explorations/index/report/index_guide.pdf.
8 Morra, Dante, et al., “U.S. Physician Practices Versus Canadians: Spending Nearly Four Times as Much Money Interacting
with Payers,” Health Affairs, August 2011, www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2010.0893.
9 Beaton, Thomas, “Payers, Providers Pledge to Improve Prior Authorizations,” Health Payer Intelligence, Jan. 18, 2018,
https://healthpayerintelligence.com/news/payers-providers-pledge-to-improve-prior-authorizations.
10 “2017 CAQH Index,” Council on Affordable Quality Healthcare, 2018, www.caqh.org/sites/default/files/explorations/index/
report/2017-caqh-index-report.pdf.
11 “Survey: Patient clinical outcomes shortchanged by prior authorization,” American Medical Association, March 19, 2018,
www.ama-assn.org/survey-patient-clinical-outcomes-shortchanged-prior-authorization.
12 “ePA National Adoption Scorecard,” CoveryMyMeds, 2018, www.covermymeds.com/main/pdf/cmm-scorecard-2018.pdf.
13 Japsen, Bruce, “Move to Population Health Hits Hospital Finances,” Forbes, Sept. 21, 2018, www.forbes.com/sites/
brucejapsen/2018/09/21/move-to-population-health-hits-hospital-finances/#bfd483f78fba.
14 “Survey: Patient clinical outcomes shortchanged by prior authorization,” American Medical Association, March 19, 2018,
www.ama-assn.org/press-center/press-releases/survey-patient-clinical-outcomes-shortchanged-prior-authorization.
15 “Health care leaders collaborate to streamline prior authorization,” American Medical Association, Jan. 17, 2018,
www.ama-assn.org/press-center/press-releases/health-care-leaders-collaborate-streamline-prior-authorization.