Staff at Arkansas’ Harmony Park Family Medicine have been excited about streamlining the prior authorization process with the goal of improving patient access to high-quality care.
THE PROBLEM
Prior authorization approval and management historically has been a burdensome process in the industry and can cause unnecessary delays in patient care, in large part due to the manual work it requires.
That was no different at Harmony Park Family Medicine. Provider staff were spending hours per day calling, emailing and faxing relevant demographic and clinical information necessary to initiate the prior authorization process with payer organizations, which typically is more of a multistep, back-and-forth interaction rather than a simple query and answer.
“We needed a way to improve the speed and transparency of the prior authorization process to reduce administrative burden and improve patient access to care,” said Yvonne Dooley, COO of Harmony Park.
PROPOSAL
Before the organization implemented automated electronic prior authorization, patients often would get frustrated with their providers because of the time it was taking for prior authorization approval. This could sometimes lead to patients abandoning the care they needed.
“Having an automated electronic prior authorization workflow would reduce the heavy administrative burden that landed on our staff’s shoulders by creating an efficient and connected process with all necessary information and requests directly in their workflow,” Dooley explained.
“In addition to making the entire process faster and more transparent, a streamlined process would speed access to care in anticipation of improved health outcomes,” she continued. “Further, the manual nature of the prior authorization workflow inevitably leads to mistakes, which can put patient care at risk, and that is another friction point we aimed to solve.”
MEETING THE CHALLENGE
To automate prior authorization, Harmony Park worked with Humana, its payer partner; Availity, a real-time health information network; and athenahealth, its EHR vendor. The three collaborated to develop an end-to-end electronic prior authorization process leveraging the Da Vinci Burden Reduction Implementation Guides.
“These guides are a set of standards designed to make the process of prior authorization more efficient and streamlined, so using them would expedite approval of these requests and deliver an improved, seamless, end-to-end experience for patients, providers and payers,” Dooley explained.
“By creating a seamless data exchange to connect the Humana and athenahealth platforms through Availity, data could be effortlessly exchanged,” she continued. “Once trained on the new workflows, this direct connection enabled our provider staff to document and sign orders to initiate prior authorization with all the necessary data and requests directly in their workflow.”
This, combined with the speed and transparency Harmony Park now has throughout the process, has removed the need for staff to spend hours making phone calls or sending emails or faxes, greatly reducing the administrative burden on staff. It also means patients can receive timelier care.
RESULTS
The results of this collaboration were so strong that Harmony Park earned a 2024 KLAS Points of Light Award for reducing inefficiencies and improving the patient experience. Specifically, Harmony Park saw improved provider efficiency, saving staff 24 hours per week in manual work.
“Additionally, because manual prior authorization processes were removed on our side as well as the payer side, patients can receive care to achieve improved health outcomes more quickly,” Dooley noted. “Within a few months of using the electronic prior authorization process, all customers using this system saw turnaround times decrease significantly, with 54% of monthly determinations requiring no authorization and 70% of prior authorization requests sent to Humana being instantly approved.
“This is due to the integration between the athenahealth system and Humana’s system, which enables robust data gathering and sharing,” she added. “These instant approvals have dramatically reduced the administrative burden, contributed to the reduced turnaround time and improved care access.”
And the new process has led to below industry-average denial rates compared with prior authorizations processed manually. Specifically, there was a reduction from multiple days to about one day, exceeding the industry averages that range from days to weeks and the seven-day target established by the CMS Interoperability and Prior Authorization Final Rule.
ADVICE FOR OTHERS
“There were several takeaways from this project that others in the healthcare industry can learn from,” Dooley advised.
“For one, it’s important to focus on a common goal. The stakeholders had many open, transparent discussions to align on what the Da Vinci standards meant, and how they should be deployed. Everyone had to adapt, share expectations, approach issues as a team, and recognize that all parties were learning.
“Additionally, it’s important to agree on what is required up front and ensure everyone understands terminologies and timelines,” she continued. “Ensuring a collective understanding of the project helps people avoid making assumptions. When it comes time to prepare for the rollout, its crucial to identify each group’s roles and responsibilities, and reach out to the right people in efficient ways.”
As always, analyzing the data, checking data accuracy and providing full data transparency will instill trust in all partners, she added.
“Lastly, understanding the cadence of releases and how each organization deploys software can help avoid or reduce potential friction and implementation delays,” she concluded. “As we look to the future, we also want to improve business logic to increase data throughput and volume.”
Follow Bill’s HIT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.