First Pst after migration to Cloud in Health care Blog

The phrase “it's complicated” resonates well in the realm of prior authorizations in healthcare. Initially devised as a cost control strategy by insurance payers, the concept of prior authorization holds merit. However, the reality unfolds as a different tale, with 94% of doctors attributing care delays and diminished clinical outcomes to prior authorization hurdles. Furthermore, one in three doctors  connect these authorizations to escalated healthcare resource utilization, manifested through patient hospitalizations and life-threatening clinical events. There is a shimmer of hope as some insurers are retracting prior authorization prerequisites for certain conditions and procedures. However, this move might produce more complexities, given the distinct protocols of each payer. The traditional manual handling of prior authorizations by most providers leaves ample room for errors amidst these changes. A viable solution lies in leveraging technology. Experian Health's electronic prior authorization software can expedite and streamline pre-certification workflows, keeping providers updated with the ever-evolving payer requirements. What are prior authorizations?  Prior authorization—sometimes called precertification or prior approval—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage. This process can be time-consuming, burdensome, and can lead to delays in patient care. Kaiser Family Foundation (KFF) says, “Prior authorization, or pre-certification, emerged decades ago to deter physicians from prescribing costly tests or procedures unjustifiably, aiming at delivering cost-effective care.” Initially, the focus was on high-cost care like chronic condition treatments. However, the spectrum has broadened, encompassing mundane clinical encounters like basic imaging or medication refills. Since 2020, a whopping 80% of providers have witnessed a surge in prior authorization volumes, stirring discussions on their necessity. The American Medical Association (AMA) critiques the overuse of prior authorization, emphasizing the administrative and clinical issues it spawns. The lack of uniform documentation requirements across payers often culminates in unwarranted care denials and treatment delays. The administrative overhead is hefty; an average doctor processes 45 pre-authorizations weekly, a task primarily manual, time-consuming, and error prone. Some insurers lifting prior authorization requirements  The scrutiny over the years has prompted some payers to relax prior authorization mandates:  UnitedHealth is reducing nearly 20% of their prior authorization requisites for a variety of treatments from spine surgery and breast reconstruction to outpatient therapies and durable medical equipment Humana has eliminated prior authorizations for cataract surgery for Georgia Medicare Advantage beneficiaries.  Following suit, Aetna has waived pre-certification for certain cataract surgeries, albeit excluding Medicare Advantage beneficiaries in Georgia and Florida. They have also ceased prior authorization for physical therapy in five states. Currently, 30 state bills aiming to rectify the prior authorization problem are in the pipeline. Washington is on the verge of introducing new mandates for both private and public payers. However, the diverse new rules from payers and legislative attempts to address the issue might create new challenges.  How to keep track of prior authorization changes  The traditional reliance on manual paperwork for prior authorizations remains predominant. Over half of the providers find the process daunting to organize and maintain. Experian Health's electronic prior authorization solution stands to help automate this process, enhancing operational efficiency and curbing costly denials. The solution auto-updates with the latest payer rules, offering real-time tracking of authorization status and allowing manual look-up by CPT code or service description. This significantly reduces the time spent hunting for updated information. Furthermore, the software can add actionable alerts, creating flags when payers change their requirements. For example, the Prior Authorization Knowledgebase, a proprietary repository for more than 160 national payers and their pre-certification rules, allows quick check functionality to see if a procedure requires appropriate use criteria adherence. Users can create service work queues when CMS requires adherence to Appropriate Use Criteria (AUC). Two supporting tools to aid these processes include the Medical Necessity tool, which validates clinical orders against CMS and private payer rules for fewer denials, and Claims Scrubber, which helps healthcare organizations prevent denials by improving claims accuracy.  Neeraj Joshi, Director of Product Management, at Experian Health, says, “Technology has the potential to significantly reduce the need for pre-authorization in healthcare by improving efficiency, streamlining processes, and enhancing decision-making. Automating prior authorizations eliminates the burden of tracking these constantly changing requirements. Following these changes by hand, scrolling back and forth between websites, then manually adding them to a rules list leaves room for error that no one can afford.”   Using technology to streamline prior authorizations Today, a mere 21% of providers have adopted electronic prior authorization software. The Council for Affordable Quality Healthcare (CAQH) projects that automation of service preapproval could slash healthcare's administrative encumbrances by $437 million annually. More crucially, it would expedite patient decision timelines and care delivery. The impact on patient outcomes could be significantly positive over time. The utilization of electronic prior authorization software promises to alleviate the anxiety doctors and patients endure while awaiting treatment approval. The AMA reports that 8 in 10 doctors acknowledge patient experience unwarranted care delays, sometimes leading to treatment abandonment due to prolonged prior authorization procedures. The technology to expedite prior authorizations is at our disposal, and progressively, healthcare organizations are transitioning towards it, mending the broken pieces of care delivery and reimbursement. Joshi says, “While technology can reduce the need for pre-authorization in healthcare, it's essential to strike a balance between ensuring the appropriate use of medical services and avoiding unnecessary delays in patient care. Healthcare providers can use technology to design more efficient workflows that minimize administrative burdens. For example, automating data entry and documentation can free up healthcare staff to focus on patient care. We have the tools available that can speed up these processes.”   Today, better health requires reducing the complexities of the healthcare paradigm. Experian Health offers provider organizations improved options for delivering care with robust technological solutions that improve the lives of clinicians, staff, and patients. We specialize in offering digital tools to improve every stage of the patient journey. Contact Experian Health today to improve your pre-approval processes with electronic prior authorization software. 

AI and automation could cut US healthcare spending by up to 10% – a promising figure for hospitals operating on razor-thin margins. Despite the potential for cost savings and revenue growth, investing in AI can seem risky while the technology feels relatively new. But as denial rates increase, staff shortages persist, and payers race ahead with their own AI-led efficiencies, investing in AI and automation could help healthcare providers increase efficiency and reduce manual workloads, while improving the patient experience. In a recent podcast interview, Johnathan Menard, VP of Analytics at Experian Health, talked to Andrew Brosnan of Omdia about how providers can use AI and automation in healthcare to reduce admin costs and tackle staff burnout, while maximizing the ROI on new technology. This article sums up the key takeaways. “AI and automation are gaining momentum in the healthcare revenue cycle, but there remains untapped potential” For healthcare leaders, maintaining the financial health of their organization is critical to serving their communities. Menard sees untapped potential to use AI to improve financial prospects by automating and eliminating administrative tasks within the revenue cycle: “There are many repetitive, tedious tasks involving large amounts of data that's already collected, and mostly structured and standardized. That can be organized and analyzed with AI to help improve efficiency and accuracy.” Automation is a well-established route to lowering manual workloads, increasing efficiencies and generating data for better decision-making. AI takes this a step further. For example, Experian Health's flagship AI platform, AI Advantage™, can parse an organization's data to identify and predict patterns in payer behavior. It translates this data into insights that help providers boost profitability and improve the staff and patient experience. Menard explains why claims management is a prime use case for AI: “Last year, the average denial rate was already above 11%. That's 1 in 10 patients potentially having to deal with uncertainty about who will pay the bill, when they should be focusing wellness. That's where we see Experian Health being able to lean in and drive value and change in the healthcare industry with AI.” “Cost is the biggest barrier to AI and automation adoption in healthcare – but can be offset with the right data” Despite the potential upside, healthcare still lags other industries when it comes to implementing AI. Menard says that workforce costs are the biggest barrier to adoption: “In healthcare, it's not just a matter of implementing the technology or solution, but also maintaining it on a yearly basis with talent. Organizations are going to have to recruit an AI-competent workforce.” He says that providers may struggle to offer competitive salaries to attract staff with this skillset, but there are other ways to offset cost concerns. One example is working with a trusted third-party vendor to choose the best-fit AI solution for their organization. These vendors can leverage economy of scale, data and lessons learned in other markets to help providers deliver new models of care: “At Experian Health, we have health data spanning eligibility and benefits, address, identity, claims remittance payments. We have insights on 300+ million consumers and 126 million households. We're able to offer providers one of the most holistic views of today's health care consumer. It gets really exciting when you think about partnering with providers to augment their capacity to deliver a different style of care.” “Providers need to make sure staff see the benefits of AI and automation” Menard notes that successful implementation of AI needs staff buy-in: “Providers need to make sure staff see the benefits of what this technology can bring. They must also make sure they give them the proper training on how to embrace these capabilities. They do not replace your job; they augment you to do more, or they allow you to focus on doing the right thing, not the right thing that needs their specific level of expertise.” AI Advantage is a prime example, reducing the admin burden for staff, who can then focus on higher priority tasks. The solution takes a two-pronged approach to help staff reduce claim denials and maximize reimbursement: AI Advantage – Predictive Denials synthesizes historical and real-time claims data and payer decisions to flag claims that are likely to be denied. This allows staff to intervene and make necessary amendments prior to submission. AI Advantage – Denial Triage performs a similar function for claims that do end up being denied. It helps staff eliminate time spent on low-value denials by guiding them resubmissions that are most likely to be reimbursed. Schneck Medical Center and Community Regional Medical Center (Fresno) are seeing the benefits of AI Advantage. Watch the on-demand webinar to hear about their results. Moving beyond proof of concept Menard acknowledges that providers need to feel confident in a tool's ability to deliver before they make an investment, especially if they are operating on single-digit margins: “You can't do that without the proof of concept. There are too many competing priorities, especially in the revenue cycle, and healthcare leaders need to be laser-focused and very confident in their decision-making.” In part, this is what Experian Health is looking to do with AI Advantage. By demonstrating the power of AI to reduce costs and alleviate staff pressures within claims management, it can act as a springboard for smarter automation across other revenue cycle operations. Menard believes that as AI adoption expands, it will become faster, easier and cheaper to develop solutions at scale: “That's why we built the AI Advantage platform – to launch other products in the future and solve other issues throughout the healthcare journey. We talked about automation, adoption and healthcare. To me, the best way to automate a process is to eliminate the need for it in the first place.” Find out more about how AI and automation in healthcare can reduce costs, prevent staff burnout and help providers prepare for future challenges.

In July this year, the Centers for Medicare & Medicaid Services (CMS) reported that a data breach in a contractor's network may have compromised the data of more than 600,000 current Medicare beneficiaries. The breach, which occurred in May 2023, involved a vulnerability in file transfer software that enabled an unauthorized party to access beneficiaries' personally identifiable information (PII) and protected health information (PHI). Some patients were issued with new Medicare Beneficiary Identifiers (MBIs) following the incident. The contractor also offered two years of Experian credit monitoring at no cost to those affected. However, providers may see an increase in patients who are confused or concerned about using their MBI card. Experian Health's MBI Lookup service can help providers ensure that Medicare eligibility verification remains as efficient as possible. Thousands of beneficiaries issued new MBI numbers In response to the breach, CMS announced that 47,000 individuals would be mailed new MBI cards with new MBI numbers. However, as 612,000 patients were affected by the breach, there may be a significant number of people whose MBIs may change without notice. Since these individuals will not be able to use their old MBIs when trying to find Medicare coverage and benefits, there could be confusion among patients and providers who rely on MBIs to confirm a patient's eligibility for Medicare coverage. It could also affect billing processes and claim status inquiries. Experian Health reached out to CMS for clarification and received the following guidance: If a Medicare beneficiary's MBI number has changed, then their old (now inactive) MBI will return an AAA72 error when attempts are made to confirm coverage using the HIPAA Eligibility Transaction System (HETS). The HETS 270/271 platform will accept historical 270 requests that use the patient's new MBI. Old MBI numbers will only be accepted if that number was active during the Date(s) of Service noted on the request. Providers should note that some patients may inadvertently use invalid MBI numbers and review processes for verifying Medicare eligibility accordingly. Verifying Medicare eligibility with Experian Health's MBI Lookup tool Verifying active coverage can be a painstaking process, but it's a vital step to confirm that planned services will be covered by the patient's insurance provider. If a patient is unaware or cannot demonstrate eligibility for Medicare, then the provider cannot make a claim for reimbursement, and the patient may be left to pay a bill they cannot afford. Finding active coverage helps providers reduce the risk of bad debt. Experian Health's Insurance Eligibility Verification speeds up this process by accurately confirming coverage at the time of service. The process comes with an optional MBI Lookup feature, which checks transactions against MBI databases to see if the patient may be eligible for Medicare. If the patient has forgotten their MBI card, the tool will check to see if they're included in the database, using their name, date of birth, and Social Security Number (SSN) or Health Insurance Claim Number (HICN). The MBI Lookup service triggers on 270/271 transactions in the following cases: Where the transaction fails because the subscriber is not found or their MBI number or other identification is missing or invalid (a “Traditional Medicare Failure”) Where a commercial 270 inquiry returns a “Medicare Advantage Plan” or “Managed Care Plan” indication on the “Other Payer” or “Other Coverage” section of the 271 response Where a commercial 270 transaction returns a failed response and the patient is aged 65 or older. If the provider's system attempts to use a patient's old number, and the patient does not realize that they have a new number or card, MBI Lookup will find and verify their new MBI. When the tool is triggered, it finds active and verified MBI numbers in 60% of cases on average. Find coverage faster with automated discovery tools Kate Ankumah, Principal Product Manager of Eligibility Verification and Alerts at Experian Health, says the automated MBI Lookup service has proven especially useful during times of change: “Providers relied on this service to verify Medicare coverage quickly when the pandemic hit, just as the industry was adjusting to the use of MBIs instead of their legacy HICN. Now, MBI Lookup can help providers smooth out the impact of data breaches involving Medicare beneficiaries with minimal fuss. It's a reliable way to give patients clarity without placing any undue burden on staff.” Insurance Eligibility Verification can be used alongside other automated coverage identification tools, such as Coverage Discovery®. Coverage Discovery scans government and commercial payer databases throughout the patient journey to find any previously unknown or forgotten coverage, eliminating the need for manual inquiries. Using multiple sources of data and tried-and-tested algorithms, these tools work together to locate coverage for patients, giving patients peace of mind and helping providers avoid uncompensated care. Both tools can be accessed via the eCareNext® platform, so staff can view eligibility responses and manage work queues through a single interface. And of course, this recent breach is a stark reminder of the need to protect patient data. Using a single vendor with integrated software and data solutions can help reduce the risk of data getting into the wrong hands. Find out more about how Experian Health's Eligibility Verification solution and MBI Lookup tool can help providers verify active coverage and give patients peace of mind following a data breach.