For physicians and practice administrators alike, understanding the benefits of streamlining prior authorization and eligibility processes is an important factor in creating a smoother patient journey. The implementation of prior authorization and eligibility solutions ensures timely adjudication of claims and minimizes administrative burden, increasing your team’s efficiency and enhancing patients’ experiences.  In this blog post, we explore how automated prior authorization and eligibility solutions can be beneficial for medical practices to reduce delays in care delivery, improve cash flow, and much more. Continue reading to find out more about introducing such solutions into your practice!

What is a Prior Authorization and Eligibility Solution 

Prior authorization and eligibility solutions are at the heart of an intelligent, automated revenue cycle management system. Utilizing prior authorization effectively can streamline healthcare processes and result in a reduction of administrative burden to ensure more efficient delivery of care. By optimizing prior authorizations prior to initiating treatment, increased accuracy of prior authorization criteria is achieved. An effective prior authorization and eligibility solution allows for rapid approval rates, meaning faster claim processing. This facilitates improved billing accuracy and reduced administrative denials resulting in a greater revenue cycle efficiency throughout the healthcare system.

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Advantages of Implementing a Prior Authorization and Eligibility Solution 

Implementing a prior authorization and eligibility solution has many advantages. It enables patient eligibility verification at the point-of-service, eliminating the need for manual billing processes and follow-up, taking weeks or even months to complete. This ensures patient care is not delayed and patient engagement is effectively improved as patient appointments are scheduled much smoother. At the same time, providers increase their compliance with payer guidelines which minimizes denials due to incorrect patient eligibility data. Furthermore, since patient info is stored in one central database, it becomes easier to update patient information which ultimately reduces administrative overhead costs and time. This makes prior authorization and eligibility solutions an invaluable asset for healthcare facilities looking to streamline their processes while improving patient care and engagement.

Learn more about navigating payer and physician compliance here.

Improved Time Efficiency 

For most healthcare professionals, improved time efficiency is essential, especially when facing staffing challenges Using prior authorization and eligibility solutions can help streamline that process - Sending all the information electronically, the turnaround time for a response is improved significantly, freeing up precious resources to focus on more patient-specific tasks. These solutions also remove any guesswork regarding coverage eligibility, providing both physicians and patients with accurate information right away. In addition, improved time efficiency leads to improved care coordination and better health outcomes overall.

Reduced Administrative Burden 

As more and more medical practices move towards electronic health records to streamline their daily workflow, they’re recognizing both the internal and external benefits, such as increasing accuracy, utilizing real-time reporting, and boosting team retention. Prior Authorization and eligibility solutions can be built into existing records systems, helping to minimize the time spent manually verifying a policy’s coverage for every patient, empowering billing teams to focus on more important objectives. Not only does this reduced burden help improve practice operations, but can also raise practice revenue with faster approval times and reduced risk of errors. Effective Prior Authorization and eligibility solutions are designed to eliminate or automate manual steps in the insurance verification process while ensuring compliance with payer rules.

Enhanced Patient Satisfaction 

Healthcare organizations utilizing prior authorization and eligibility solutions can significantly improve patient satisfaction by enhancing their overall experience, from time-of-service to bill-pay. By reducing administrative burdens for enhanced understanding, patients are provided with more time to focus on their healthcare needs and decisions without being bogged down in paperwork, or hit with a surprise bill. Additionally, providers gain enhanced visibility into the treatment timeline enabling them to better track and manage the process resulting in enhanced patient outcomes. Ultimately, this enables enhanced patient satisfaction and improved overall experiences for both patients and providers alike.

  • Validation
    First, the payer automatically verifies authorizations that are present on the patient’s record. This ensures that the procedure(s) and approved date ranges are accurate. Then, if an Authorization number fails validation, the system automatically looks for a valid Authorization on-file with the payer and returns that value to the user. This way the registration system can be updated.
  • Automated Authorization Acquisition
    To begin, the system uses the data collected from the physician’s office portal, or staff at the hospital, to submit the request for authorization. It then queries the payer to check for either denial of authorization, request for additional information, or the authorization number. In short, the process uses technology for transactions when supported by the payer, or web harvesting technology to query the payer. Thus, it manages the communication with the physician’s office and hospital staff to complete the authorization process
  • Authorization Dashboard
    The authorization dashboard communicates the result of “Automated Authorization Acquisition” to the hospital / facility staff through various alerts, for hospital-initiated authorization requests. When the automated process has obtained an authorization, the alert informs the staff of the need to call the patient to schedule the appointment. When additional information is needed to complete the authorization, the alert then instructs the user to contact the appropriate party. If the facility has not responded to requested information or when a request for authorization has been denied, the system generates a corresponding alert for the user.

How to Get Started with Prior Authorization and Eligibility Solutions 

Prior Authorization and Eligibility Solutions can be complex and time-consuming, but they are essential tools for streamlining medical processes. Fortunately, it's easier than ever to get started with these solutions – the ImagineSoftware team is here to help! To start, assess your current Prior Authorization and Eligibility process to ascertain where improvements can be made. After this initial assessment, you should develop a Prior Authorization and Eligibility strategy that will help to grow savings for your organization. Then, find the right technology that works for you so you can access timely clinical insights and ensure compliance with regulation changes. With the right Prior Authorization and Eligibility Solutions in place, you'll have an effective system driving successful results without having to take up too much of your time.


Key Factors to Consider When Implementing a Prior Authorization and Eligibility Solution 

An effective Prior Authorization and Eligibility solution can provide immense benefits to healthcare organizations, improving efficiency, accuracy, and cost savings. When seeking a solution for this purpose, it is important to consider several key factors. These include the ability of the solution to deliver real-time access to applicable payer information, within a configurable dashboard, for a given patient, as well as seamless integration with existing systems throughout the organization's workflow. Additionally, customizable workflows should be considered to improve efficiency for each organization's unique environment. It is also recommended to look for solutions that provide transparency in cost savings analysis and functionality that enables Medicare risk assessment capabilities. Implementing such solutions will have a long-term impact on an organization's revenue cycle management process, so researching options carefully will yield the best outcome.

Benefits of Proactive Monitoring for Prior Authorizations and Eligibility Solutions 

Proactively monitoring prior authorizations and eligibility solutions brings several benefits to healthcare organizations. First, it enables proactive decision making, with real-time reporting and configurable dashboards, allowing better utilization of available resources while improving accuracy in verifying coverage. This means avoiding any preventable denials of service and reducing the burden on administrative staff. It also allows providers to review their eligibility data without having to manually check every patient or claim; instead they can focus on patients who require their attention. Finally, proactive monitoring allows for deeper understanding of claims patterns and discrepancies, helping providers proactively develop strategies for ensuring acceptable payments for services rendered.

Integrating Your Existing Systems with New Prior Authorization and Eligibility Solutions

Leveraging integration capabilities when implementing new Prior Authorization and Eligibility solutions can be tremendously beneficial for your medical practice or billing organization. By connecting your existing systems to the new solutions, you can automate many of your manual processes to improve accuracy and efficiency. Integration also allows you to streamline cross-system communications by eliminating the use of disparate methods. This helps reduce operational costs while ensuring uniform data integrity across all systems. By taking advantage of integration capabilities, your organization will be well-positioned to maximize its Prior Authorization and Eligibility solutions and operations more effectively.

Prior Authorization and Eligibility solutions are a great way to improve the efficiency and accuracy of patient care while reducing administrative burden. With improved time efficiency, reduced administrative burden, and enhanced patient satisfaction, it is clear these solutions hold significant potential. Once an organization has decided to begin implementing a Prior Authorization and Eligibility Solution they need to consider key factors such as cost constraints or provider incentives when doing so. Proactive monitoring can help organizations identify problems quickly and reduce their impact. Integrating new solutions with existing systems can also ensure that processes run smoothly. All in all, by automating prior authorization and eligibility workflows, organizations can save time, reduce errors, increase accuracy, enhance satisfaction levels for patients and providers alike - ultimately delivering better care more efficiently. It’s time for organizations to take advantage of what a Prior Authorization and Eligibility solution offers - automate your workflows now!

Learn more about ImagineSoftware’s automated revenue cycle management platform, including state-of-the-art prior authorization and eligibility technology here. Feel free to reach out to us for a one-on-one conversation, where we’re happy to provide comprehensive information about our services and how we can benefit your unique organization.


Caroline Smith

As ImagineSoftware’s Senior Marketing Campaign Specialist, Caroline manages and implements marketing initiatives, promoting technology innovations and expanding the company’s brand across various avenues. Caroline’s goal is to advance ImagineSoftware’s client, partner, employee, and public awareness, driving the company’s marketing strategy with creative, innovative, and effective marketing tactics.