Streamlining Prior Authorizations: Optimizing Oncology Billing

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Streamlining Prior Authorizations Optimizing
Oncology Billing
Prior Authorization (PA) stands as a critical
component in the realm of Oncology billing, a
pivotal force in the delicate balance of
providing cancer care while ensuring financial
stability. A recent survey of 700 oncologists
highlighted challenges, with 93 percent of
patients experiencing delays in critical
treatment due to PA requirements, and a notable
31 percent reporting delays exceeding four to
five days. Published by various medical
organizations, this survey aimed to spotlight the
growing issue of Oncology Prior Authorization in
medical billing services. Originally conceived
to control costs and protect patients from
unexpected bills, PA has inadvertently led to
administrative burdens, heightened claim denials,
and care delays. These challenges adversely
affect providers' financial performance and
create undue stress for billing teams and
patients. Addressing the root causes of process
delays, administrative complexities, and claim
denials that result in write-offs is intricate,
particularly with the rising PA demands from
payers. Implementing the following solutions to
optimize the oncology billing
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Streamlining Prior Authorizations Optimizing
Oncology Billing

• Automated Eligibility and Patient Financial
  Responsibility Systems Integrate AI-enhanced,
  real-time PA technology early in the revenue
  cycle to reduce errors, minimize manual work, and
  accelerate patient care. This includes the
  ability to automatically identify whether PA is
  required and determine the optimal submission
  route.
• End-to-End Approach Develop a fully integrated
  approach encompassing a master patient index
  (MPI), direct real-time connections to most
  payers, an extensive library of payer rules, and
  integration with various systems such as EHR,
  LIMS, HIS, and RCM solutions. Incorporate a
  self-learning system that uses AI to dynamically
  update automated workflow and rules engines based
  on actual PA responses.
• Automated Revenue Optimization Tools Integrate
  tools for demographic verification, insurance
  discovery, self-pay analysis, and deductible
  monitoring to enhance efficiency.
• To optimize oncology billing, focus on the
  following key strategies
• Gold Card System Informed providers adhering to
  payer requirements can reduce the need for prior
  authorizations, freeing up valuable time for
  higher-priority tasks.
• Automation of Prior Authorization Leverage
  automation to enhance the accuracy and efficiency
  of the pre-authorization process, aligning with
  the CAQH report's suggestion to increase
  electronic submission.

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Streamlining Prior Authorizations Optimizing
Oncology Billing

• Transparent Systems between Payer and
  Provider Foster clear and transparent
  communication between providers and payers
  regarding prior authorization guidelines and
  supporting documents. Utilize initiatives like
  CMS's secure environment for instant
  identification of PA needs.
• Acceptance of Previous Insurers
  Authorization Simplify processes when patients
  change insurers, ensuring timely care and
  reducing unnecessary costs.
• Speed Up Prior Authorizations Overcome delays
  caused by manual methods and legacy systems by
  leveraging automation solutions. The AMA report
  emphasizes the importance of speed in preventing
  patient treatment abandonment.
• Elements to look for in an Oncology Prior
  Authorization in medical billing service
• Participates in value-based care programs
• Adheres to NCCN Guidelines at the point of care
• Authorizing treatment costs and coverage for
  patients
• Accessing physician orders
• Data captured as required by insurers for prior
  authorization submissions
• Real-time information is passed to doctors.

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Streamlining Prior Authorizations Optimizing
Oncology Billing

• A fully integrated, end-to-end approach includes
• A master patient index (MPI) that can identify
  each unique patient
• Direct, real-time connections to most payers
• An extensive library of payer rules that
  synchronizes eligibility and PA rules
• Integration with workflows and systems like EHR,
  LIMS, health information system (HIS),
  and revenue cycle management (RCM) solutions
• A self-learning system that uses artificial
  intelligence (AI) to dynamically update automated
  workflow and rules engines based on the actual
  responses and results from submitted PAs
• Ability to integrate with automated revenue
  optimization tools, such as demographic
  verification, insurance discovery and
  verification, self-pay analysis, and deductible
  monitoring
• Ability to validate a PA request against payer
  guidelines, automatically submit it, and then
  receive instant decisions from the payer.
• Building upon automated eligibility and patient
  financial responsibility systems, providers can
  add AI-enhanced, real-time PA technology to drive
  the end-to-end PA process as early in the revenue
  cycle as possible. 

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Streamlining Prior Authorizations Optimizing
Oncology Billing

• 5 key strategies to boost prior authorization for
  optimizing oncology billing
• 1. Gold card system
• Care providers who are well-informed and adhere
  to the payers specific requirements neednt have
  to get prior authorizations. Physicians are
  reported to spend a whopping 15 hours every week
  on prior authorizations, and even cutting this in
  half the time could make a huge
  differencehelping you spend more quality time on
  higher-priority tasks.
• 2. Automation of Prior Authorization
• Automation is one of the key strategies that can
  simplify and improve the accuracy of the
  pre-authorization process by quickly identifying
  the most suitable treatment or medication. A
  Council for Affordable Quality Healthcare (CAQH)
  report indicates that just 12 percent of prior
  authorization requests are made electronically
  against 100 percent of claims submitted
  electronically.
• 3. Transparent Systems between Payer and Provider

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Streamlining Prior Authorizations Optimizing
Oncology Billing
Clear and transparent communication between
providers and payers regarding the guidelines on
services that need prior authorization and the
supporting documents requiredwould help
streamline the overall process. To support this
drive, the Centers for Medicare Medicaid
Services (CMS) has announced an initiative that
allows providers to interact with the payer
platform through a secure environment to
instantly identify whether or not a specific
process needs prior authorization and the
relevant documents required for the
operation. 4. Acceptance of Previous Insurers
Authorization When a patient changes their
health insurance provider, a whole new process
and repeated protocols are usually required
before treatment, which could tremendously impact
the patients health condition and additional
treatment costs for the Physician. Establishing a
streamlined approach to accepting the previous
insurers prior authorization could go a long way
in delivering timely care to the patientswhile
driving down unnecessary costs. 5. Speed Up
Prior Authorizations
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Streamlining Prior Authorizations Optimizing
Oncology Billing
Manual methods and legacy systems could
drastically slow down the pre-authorization
processnegatively impacting patient care and
outcomes. An American Medical Association (AMA)
report shows that about 65 percent of Physicians
reported at least one day of the delay in prior
authorization process and 27 percent of them
reported a delay of three days or more. This
delay often causes patients to abandon
treatments, which can be prevented by leveraging
automation solutions to speed up approvals.
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Streamlining Prior Authorizations Optimizing
Oncology Billing
CONCLUSION Streamlining prior authorizations is
crucial for optimizing oncology billing and
ensuring efficient claims processing. By
implementing strategic measures, oncology
practices can navigate the complexities of prior
authorizations, reduce delays, minimize denials,
and ultimately improve patient care and financial
performance. Ready to optimize your oncology
billing and streamline the Prior Authorization
process? Take the next step towards efficient and
effective healthcare management. Contact us
today to explore tailored solutions that enhance
patient care, reduce delays, and boost financial
performance. Your journey to seamless oncology
billing starts herelet's elevate your practice
together!