ROI of a Prior Authorization Specialist

Prior authorizations (PAs) can be a costly step that gets in the way of patient access. Data from EviCore Healthcare shows that on average, each prior authorization costs $11 for providers and that it has a detrimental impact on patient adherence where approximately half of patients struggling to adhere, especially with specialty products. So, why are PAs a regular market access roadblock?

There is no question that pharmaceutical companies today are developing more complex drugs with more sophisticated delivery systems and mechanisms of action. The same is true for medical devices, which have played a greater role in more chronic diseases such as Type 2 Diabetes.

Although, these advances have resulted in life-changing treatments for patients, they are costly. For example, specialty products average $4,500 per month. In fact, some can cost upwards of $1 million per year. Nonetheless, cost should not limit a patient’s access to care.

Although payers have found ways to optimize patient and market access, they are still requiring prior authorizations for complex transactions. Estimates are that the labor costs associated with PAs are over $32 billion annually.

Why are Prior Authorizations a Burden?

Prior authorizations are implemented to ensure appropriate care is given to patients, but these checks can lead to delays in care. It can take days or weeks for prior authorization approval, sometimes even months. This time may not seem like much, but for many this could be the difference of quality of life or general function.

According to the 2019 AMA prior authorization (PA) physician survey, prior authorizations are taking 14.4 hours a week per physician. This is a notable amount of time for a physician or their support staff. Additionally, the findings show that only 30% of physicians have staff dedicated to working on prior authorizations. That is, 70% of physicians giving that responsibility to other professionals in the practice who already have other functions.

Additionally, many prior authorizations are not a direct revenue stream for physicians. Rather, they are a time drain. And therefore, also drain resources. They require countless administrative tasks that can consume a good portion of the day if you aren’t familiar with the process or don’t know where to look for the information requested.

In business and healthcare, time equals money. One way to curb costs would be better prior authorization training to help staff figure out how to process prior authorizations.

Overhead vs. Efficiency Costs

COVID-19 is making it hard to stay afloat in private practice while overworking healthcare professionals in the hospitals. There have been trends in eliminating overhead costs, but is this practice saving money?

The answer is unlikely. If you lose efficiency, you lose revenue and you waste time. For those positions that are being combined or removed, who is picking up those essential tasks?

The sad truth is that, a cumbersome administrative process such as PAs may force physicians and other ancillary healthcare providers (HCPs) to divert time away on what they are there to really do- namely, improve patient health outcomes.

Therefore, proper training and certification of professionals for prior authorization and the reimbursement processes are essential to ensure reimbursement and greater overall quality of care for patients.

With a PA specialist, you don’t need to rely on the nurses to do the prior authorizations. You make the nurses more efficient and a physician can see more patients. For 99% of healthcare practice, the integrated prior authorization specialist is a smart choice. Whether it is buy and bill, infusion, or maintenance medications – you don’t waste time by giving prior authorizations to those who aren’t trained in making the process go smoothly.

Return on Investment of a Prior Authorization Specialist

There are a few ways to increase revenue in healthcare – increase reimbursements, decrease overhead costs, or increase efficiency. We are currently seeing trends for decreasing overhead costs, but that doesn’t have to mean laying someone off.

Allocating tasks to the appropriate team members and increasing efficiency can lead to decreasing overhead costs and increasing revenue. The physician’s healthcare practice makes money when the physician sees a patient. For every patient the physician sees, they get approximately $75-100 per visit.

Physician time = revenue

Therefore, the physician should not be spending time on tasks that are not directly related to the patient’s care or patient experience. For every time slot the physician cannot see a patient due to administrative tasks, the practice loses money.

Processing prior authorizations can cost physicians $67,392 of their time per year (based on conservative $90/hr).

For the same cost, you can:

Hire a full-time prior authorization specialist
Spend significantly less time dealing with payers
See an additional 36 patients/week
Make an additional $140,400/yr (based on $75 per visit)

Benefits of a Prior Authorization Specialist

There are countless benefits to having a prior authorization specialist on your team, including:

Improve efficiency
Increase face-to-face time with patients
Less time dealing with payers
Higher patient satisfaction
Additional patient appointments
Less staff burnout

Investing in PACS for your employees

Having Prior Authorization Certified Specialists (PACS) on your team yields better results and fewer denials. They are an asset whose primary focus ensures reimbursement and optimizes the efficiency of the healthcare practice. The PACS program is a self-paced, online, accredited certification program that focuses on the prior authorization, ensuring approvals, minimizing denials, and navigating the payer requirements.

With PACS, you will see positive benefits: