Necessities for a Winning Audit and Authorization Strategy

By Scott Overholt, director of business, Vyne Medical
Twitter: @VyneMedical
Twitter: @ScottOverholt

Payer-required administrative tasks are a burden most providers know all too well. They are a daily source of frustration, diverting time from mission-critical work and often delaying patient care. Legislation impacting audit and authorization processes is in constant flux, only increasing confusion about payer requirements and regulations.

Regardless of legislation changes, you can get ahead of the game and reap significant benefits from streamlining and simplifying workflows around authorization, audit and appeals management. The following initiatives represent opportunities for time and cost savings, improved payer response times and reduced care delays – all benefiting both patient care and the organization’s bottom line.

Electronic submission of medical documentation

Many have already made the move to at least a partially digital process for submitting medical documentation to payers. A fully electronic exchange accelerates the submission of documentation to help ensure timely filing and eliminate lost responses. Electronic submission is also shown to cut time needed for payer review and approvals in support of more expedient patient care delivery.

In 2011, the Centers for Medicare & Medicaid Services (CMS) launched the Electronic Submission of Medical Documentation (esMD) initiative to assist providers in the submission and tracking of audit documentation. The program now represents a completely electronic bi-directional exchange of information between providers and Medicare contractors and supports pre-and post-payment audits, first and second level appeals, Recovery Audit Contractor (RAC) discussion requests, advanced determination of medical coverage, unsolicited claim documentation, and prior authorization responses.

According to CMS’ CERT Research and Statistics Data, one of the major reasons for a RAC denial is lack of documentation, which occurs when a provider fails to appropriately respond to an Additional Documentation Requests (ADR), either by neglecting to respond or by stating that they do not have the documentation requested. By digitally transmitting request and response data, you can reduce the risk of losing audit notifications and ADRs, as well as show timely filing with digital proof of receipt by RACs and CMS. This supports the integrity of audit response data and reduces your risk for a denial.

Electronic prior authorization process

Another area presenting significant workflow challenges is prior authorization, a utilization management tool used by health plans to control costs. In a May 2021 stat poll by the Medical Group Management Association, 81 percent of respondents stated that prior authorizations had increased over the previous year, with some having to add full-time positions just to handle the workload. Challenges include inconsistent or vague payer requirements, frequent updates, increasing claim denials, and slow responses from payers.

To address these challenges, CMS moved to facilitate electronic exchange of prior authorization data. According to a study by America’s Health Insurance Plans (AHIP), submitting an electronic prior authorization request reduces the median payer response time by 69 percent, which is three times faster than when submitting a manual request. The study also found that an electronic process resulted in fewer patient care delays, reduced administrative burden and improved information for providers.

CAQH CORE, a group of stakeholders working to reduce the administrative burden of the authorization process, has established operating rules to ensure that electronic prior authorization information is standardized and shared in an organized and trusted manner. The guidelines – which set clear expectations for initial response times, requests for additional documentation and final determinations – are intended to accelerate adjudication timeframes and reduce resources spent on manual follow-up.

Track authorization status

To succeed in managing payer authorizations, audits and appeals, it’s critical to keep a close eye on all incoming and outgoing communication with payers, health plans and review contractors. An electronic workflow simplifies the process by keeping a digital record of the timeframe of requests, submissions and responses – and the deadlines associated with each one. Recording conversations with payers is another important strategy to establish proof of information communicated in-person or by phone.

Dashboards are helpful in tracking submission status, as well as giving alerts regarding authorization status, denials and approvals. If your organization is struggling to file responses on time, an action plan can help. Delays can be addressed by analyzing factors such as the number of staff touches involved, number of software tools in place and potential internal bottlenecks. By removing duplicate steps, centralizing data and consolidating technology, you can mitigate delays that could otherwise negatively impact patient care.

A cross-functional team with representation from both clinical and administrative areas should work together to set baseline KPIs for authorization performance. Examples of important KPIs to track are the number of prior authorizations submitted by payer, total average time to receive a response by payer, most common ICD-10 codes submitted, authorized and rejected (along with reasons for rejection), and medical necessity pass rate, or rate of acceptance for authorizations with medical necessity content.

Consolidate authorization, audit and appeal data

A common struggle in managing payer requirements is the lack of a consistent process for receiving and responding to payer requests. Some responses are mailed, some faxed, some sent electronically, and some communicated by phone. As a result, data is stored in disparate systems making it difficult to find when facing a payer deadline. This can be particularly challenging when attempting to collect information previously submitted along with additional documentation to substantiate a claim.

Tools that support data collection, recording, submission and tracking are needed to assist providers in successfully managing payer administrative requirements. Of equal importance is centralizing authorization, audit and appeals data through a single interface and indexing it to the patient record for enterprise access, retrieval and exchange. Documentation is a critical lifeline for providers in managing payer administrative requirements. A clear workflow is needed to collect necessary documentation and ensure all materials are included for the dates under review.

While various technology platforms are available to manage the process, providers should select a system that facilitates CMS’ esMD and eMDR programs, supports electronic attachments for medical claim ADRs, and enables electronic submission of prior authorization. A comprehensive platform gives you access to all documentation within your system to prove the appropriate level of care and submit it electronically to help ensure the maximum allowable reimbursement for services delivered.

Benefits of electronic submission and tracking

The costs related to payer administrative requirements are significant, both in time and resources. A comprehensive platform for electronic authorization and audit workflow management can help improve your organization’s bottom line while expediting patient care.

Consider the following benefits:

  • Response times: faster authorization responses for improved patient throughput
  • Payments: payment turnaround within days vs. weeks with manual process
  • Automation: reduced manual data entry, copying, mailing, and faxing
  • Lower costs: reduced hard costs like paper, printing, postage, packaging, and faxing
  • Security: encrypted exchange of medical documentation
  • Tracking: electronic audit trail of documentation delivery and receipt
  • Claim management: timely record submission and reduced rework requests

Changes in payer administrative requirements are certain to continue in the months ahead. A solid strategy for audit and authorization management, and a reliable platform for workflow improvement, are essential investments to ensure your organization is prepared for whatever changes may come.