Nurse on a tablet computer

Solving BI and PA problems through Workflow Automation 

Efficiencies in workflow and the ability to automate benefit investigations deliver better outcomes for not just the provider, but all parties involved.

Specialty healthcare practices, manufacturers and insurance payers are gearing up for their busiest time of year. As patients receive new benefit packages January 1, most key players in the specialty healthcare ecosystem are rushing to make sure there is no lapse in coverage and that patients can continue down, or start, the treatment plans they need.

There seems to be somewhat of a misconception about the entire verification process and so much talk is dedicated strictly around the enigma of “prior authorization”, specifically for specialty medical benefits due to the high cost of the treatment. What most don’t realize is that the entire medical benefits verification process starts with the “benefits investigation” (BI). Without the initial BI, prior authorization can’t happen.

A good BI allows the practice and patient an understanding of the cost of the medication and the expected reimbursement of the drug for a specific time-period. Results should include an idea on what deductibles are involved, applicable co-pays, and additional insurance requirements such as if a prior authorization is needed. Usually, there’s a significant amount of legwork required to identify submission criteria, all of which needs to be gathered and submitted on different submission portals. Despite the practice’s best effort, it’s an incredibly inefficient process. Many times, submission requests are denied due to typographical errors and missing information by practice staff and kicked back, starting the entire process all over again and further dallying patient care. This is a burden at any time, but particularly challenging now due to staffing shortages.

According to a recent study by the AMA, practices are known to dedicate at least two full days of administrative work and repetitive data entry acquiring the information needed for patients to begin therapy. Doctors haven’t been quiet about the toll and burnout that the approval process has had, and that the paperwork has gotten out of hand. The average physician must seek approval for dozens of approvals of prescriptions and medical services each week causing employee burnout and a preposterous $26.7 billion in time each year.

This process is ripe for change and in dire need for a more modern approach. Exploring the use of technology such as eBlu Solutions, opens limitless possibilities in terms of practice savings, overall efficiencies, and patient success. By implementing BI and PA software into the workflow, patients will not only have timely access to the care they need, but administrative demands on physicians and staff will be drastically reduced.

Manual Processes

The typical benefits investigation and prior auth process that a specialty medical practice follows is, at best, cumbersome. Multiple, manual touch points by specialty healthcare providers, manufacturers, payers and third-parties, delay the time to treat and create treatment barriers. Let’s take a little closer look at what the manual process could look like for a specialty HCP.

  • The patient is diagnosed and identified for treatment
  • A benefits verification is ran to determine treatment cost
  • Administrators juggle between multiple hubs and the insurance companies, submitting multiple rounds of phone calls, faxes and conversations to acquire necessary information
  • Determination is made as to where the treatment will be administered
  • Prior authorization in submitted with additional phone calls, faxes and conversations
  • Finally, treatment can begin

Total time from ID to IV:  Approximately 8 weeks 

Automated Process

A BV/PA software solution can offer the ability to automate the more menial tasks in the process such as logging into payer sites, manufacturer hubs, and eliminate the need for dialing phone calls and faxes. A robust solutions should also keep track of changing prior authorization rules and requirements. Reminders for re-verifications should also happen automatically. A good workflow automation can speed up the benefits verification and prior authorization process significantly

Total time to treat  from ID to IV:  Approximately 2 weeks

Making providers and patients wait weeks and weeks to start medication that could potentially change their quality of life for the better is agonizing and, quite frankly, unfair. There’s simply no reason to make a patient wait when automated workflows can provide results in real-time. With the New Year quickly approaching,  it’s exceptionally important to try and relieve the strain on practices. There’s no time better than now to implement software technology to ease the burden on staff and make their busiest season a little less stressful. When implemented and utilized, BI and ePA software can take the lift off your practice resources and shorten the time to treat.