The DME prior authorization process allows your healthinsurer to assess if a specific drug is necessary to treat your medicalcondition. One needs to consult the physician to figure out if theprescriptions are covered under the design to prevent paying the full cost ofmedications that aren't.
The change of time
Giving patients the correct care at the right time has grownincreasingly difficult. Primarily the squabbles between cost-conscious insurersand patients and their providers are unlikely to go away anytime soon.
Finding innovative ways to improve care delivery has been agoal for many healthcare executives as the healthcare landscape continues toget more complex and providers look for new ways to improve treatment whilemanaging the bottom line.
American MedicalAssociation (AMA) Findings
DME Prior authorizations are one of the most difficultaspects of providing timely care to patients. According to an AMA poll of 1,000practicing physicians, 86% of them rated the administrative burden of DME priorauthorization as "high or extremely high," and 88% indicated the loadhad increased in the last five years.
According to estimates, DME prior authorizations are up 14%year over year and up 27% from the index in 2016. As the number of DME priorauthorizations grows, so does the need to manage the growing number ofobstacles in providing treatment.
American HospitalAssociation (AHA) Report on claim denials
According to a fresh report from the American HospitalAssociation (AHA), hospitals and medical systems are seeing an increasingnumber of claim denials. Particularly with private plan DME prior authorizationconcerns driving the current surge (AHA). According to the AHA, 89% ofhospitals and health systems have seen an increase in claim denials in the last three years, with 51% reporting a “considerable” increase.
· Post-paymentaudit denials
· Partialor line-item denials
· Downcoding
Are all methods used by commercial health insurers to denyclaims. DME Prior authorization, on the other hand, was blamed by surveyrespondents for claim denials and reimbursement delays.
Reasons behind DeniedClaims
According to the survey, failure to acquire DME priorauthorization was one of the most common grounds for a commercial health plan'sclaim denial. In some cases, respondents said that plans denied claims despite theclinicians couldn't wait for a response to DME prior authorization requestbecause treatment had already commenced or a patient's condition had altered during the approved procedure. These claim denials are just adding to the stress that hospitals and health systems are already dealing with when it comes to DME prior authorization.
What actions arerequired to reduce the burden of DME Prior Authorization?
According to a quoted survey conducted by the AmericanMedical Association, many healthcare offices work an average of 2 business dayseach week addressing DME prior authorization requests. Moreover, 86% evaluatethe hardship of prior authorizations as high or extremely high.
Standardize the DMEprior authorization Process
Most healthcare providers along with the hospital groups haveurged the state-federal agencies, including the Centers for Medicare andMedicaid Services (CMS) and state insurance commissioners. Primarily tostandardize the format for communicating services that requires DME priorauthorization, the format of DME prior authorization requests and responses, and response timelines, particularly the appeal process.
However one needs to establish standard criteria for properlevels of DME prior authorization and penalizing plans for improper denials. Allthis might necessitate states and federal agencies acquiring additionalauthority.
Introducing AI in PriorAuthorization
Most healthcare providers and firms should immediately startimplementing the use of artificial intelligence (AI) to automate and standardizethe DME prior authorization process. It makes the system more dependable andscalable across all of their sites. Artificial intelligence technologies maygather relevant clinical material straight from the EHR, grade clinical papers against payer medical necessity requirements, generate an authorization submission, and follow the authorization through approval.
The new system provided schedulers with a single DME priorauthorization platform. This allows them to spend less time preparing priorauthorization submissions. A real-time dashboard provided managers with abird's-eye view of all previous authorizations, their return times, and theanalytic results.
Key takeaways
The process of DME prior authorization is an extremelysophisticated and sensitive process to deal with. Hence, it requires the mosthighly rated skilled staff to work for. However, due to the current globalpandemic situation, hospitals and healthcare firms are experiencing an acuteshortage of such skilled employees. Therefore, it’s imperative to figure out a faster and smoother solution that can provide potentially useful instruments in their drive to provide better, more timely patient care.
