Pre-service tasks—insurance eligibility verification, securing prior authorizations, and clarifying patient financial obligations, are fundamental in establishing a resilient and efficient revenue cycle—sets the stage for both financial health and enhanced patient experience. In the modern healthcare landscape, mastering these components is imperative.
The integration of comprehensive pre-service tools can ensure a seamless journey from initial patient interaction, thereby solidifying the organization’s financial foundation and fostering a sustainable healthcare delivery system.
Automating Prior Authorizations. According to the American Medical Association, prior-authorization denials on inpatient accounts are a key driver behind the dollar value of denials increasing to 2.5% of gross revenue in August 2022 from 1.5% of gross revenue in January 2021. 1 Identifying and addressing the root cause of authorization-related denials is critical to improving financial performance.
For example, many provider organizations rely heavily on phone and fax machines to process prior authorizations. CAQH estimates that the majority of providers continue to manually prior authorization requests. 2 This forces staff to leave their primary workflow—the EHR. This is often a significant drag on productivity for hospitals and health systems processing a high volume of prior authorizations and referrals.
Leveraging direct integrations with EHR systems and connections with health plans nationwide can significantly streamline the prior authorization process. Automating these tasks for fast and accurate submissions, including determining authorization necessity and clinical documentation attachment, is vital.
Other benefits of automation and direct connections to health plans include:
Efficient Coverage Discovery. Identifying insurance coverage—particularly when not immediately apparent, or with ancillary services where patients don’t see registration, like labs, ERs, or imaging—is a critical pre-service task. Tools that efficiently search for active coverage across multiple payer sources and automatically update EHR systems with relevant payer and plan codes can greatly enhance workflow efficiency and patient record accuracy.
Advancing Patient Financial Clearance. Sophisticated tools for patient financial clearance remove the guesswork from patient estimations and coverage screening. Integrated demographic, coverage, and patient responsibility information, combined with government mandate compliance and price transparency tools, are essential for tailoring workflows to specific organizational needs.
Addressing front-end gaps in the revenue cycle can mitigate issues related to claim denials and patient payments. Accessing comprehensive eligibility and benefits information within user interfaces and through real-time EHR integrations is critical.
A robust pre-service strategy is integral to a healthy revenue cycle. Embracing technological solutions and best practices in pre-service components streamlines operations and positions healthcare organizations for financial success and improved patient experiences.
Learn more about what Availity offers and discover informative resources here that can help you get started on the path to revenue cycle success.
Krisi Hutson serves as the Senior Director of Solutions at Availity, where she is passionate about creating outcomes that improve the patient experience while easing the burden on both providers and payers. With a passion to serve as a provider advocate in the healthcare ecosystem, she enjoys using technology to allow providers to focus more on their patients, and payers on their members. Krisi’s career in healthcare began more than 25 years ago and she has played a critical role in leading Availity’s revenue cycle management activities over the last decade.
Prior to joining Availity, she held positions as a Compliance Officer and Revenue Cycle Director for a large specialty practice, along with experience at hospital and Ambulatory Surgery Centers. With a personal goal of improving the healthcare ecosystem for all, she enjoys helping clients create efficiencies and meet their revenue goals to be able to improve patient care in their respective communities. Krisi has been named a “Women to Watch in Healthcare IT” by Becker’s Healthcare.
Krisi Hutson
Senior Director of Solutions at Availity
