Using PROs for Prior Authorization

Updated 6/9/2021

Prior Authorization can be messy

Anyone working in a clinic knows that one of the easiest ways to derail your day is by encountering a situation that needs prior authorization. Obtaining prior authorization for surgical procedures is…a pain in the neck. At best, it is a headache to need to submit a bunch of information to insurance companies and a waste of valuable time waiting for a response. At worst, it can cause surgery cancellations or continuum of care delays. The idea of adding another layer of complexity to the already cumbersome prior authorization process has led to a collective groan heard around the country. Different insurers with different requirements creates an administrative challenge for providers and staff seeking prior authorizations.

What is changing for prior auth collection?

Insurance companies are starting to require that patient-reported outcome (PRO) surveys be completed as part of the total joint replacement prior authorization process. These surveys are generally in the form of HOOS, KOOS or WOMAC scores. These surveys are by no means a ‘quick form’ that patients can mindlessly fill out. Each survey includes on the upward of thirty (30) questions and requires thoughtful responses. After the survey questions are answered by the patient then a staff member must score the survey. While it is still being determined exactly how this process will work from payer to payer, the one thing we all can agree on is this process will add time and energy to an already cumbersome process. CODE also knows that this is just the starting point.  Total joint replacements are the gateway to the entire orthopedic surgical population requiring PROs for prior authorization.

According to the American Medical Association (AMA ), 90% of physicians reported that prior authorization requirements negatively impacted patient clinical outcomes, with 30% of those leading to serious adverse events. Contrast that with a mere 15% of doctors believing that criteria is fully evidence-based. There is a disconnect between insurance companies and health care professionals, and the gap must be filled. So since we know that Prior Authorizations are here to stay, the question becomes how can we meet requirements with the minimum amount of headache and working hours?

How can we keep the process classy and quick?

We think while payers are hoping to use patient-reported outcomes to determine the potential value of a given procedure, healthcare organizations can use them to meet prior-authorization requirements, increase reimbursements and improve patient outcomes.

Prior authorization is making it more important than ever to have a good system in place for collecting PROs. These PROs can be collected either in-clinic, using a tool like CODE’s “Send Survey Now”, which allows organizations to create and submit a custom form to each patient and within the population they fit, or PROs can be collected out-of-clinic with an end-to-end collection platform and service.

Here is the good news…at CODE we are passionate about helping our Clients collect, use, and LOVE PRO data. We have awesome ideas for how we can help your team with a quick fix for prior authorization that is minimally disruptive to workflow, and more importantly, teach you how to incorporate this valuable outcome data into your practice to improve quality, increase shared decision making and so much more.

Using the right tool

These PROs can be collected either in-clinic or out-of-clinic.  CODE’s in-clinic “Send Survey Now” solution allows the staff member to submit a form and/or survey on-demand. Although Prior Auth processes are varied across insurance companies, we can make sure that these processes do not slow Prior Authorization down. With CODE pre-op PROs collection, we can collect your Prior Auth at the same time with our Send Survey Now tool. This permits healthcare organizations to meet regulations, obtain faster reimbursements and let providers, surgeons and staff get back to patient care rather than administrative bottlenecks.

Prior Auth doesn’t need to be a hurdle – CODE makes it just another step you don’t have to worry about.