Gastroenterology Challenges: The Impact of Prior Authorization on Patient Care

Prior authorization requirements are a key example of a revenue cycle challenge that can have downstream impacts on patient care. In the gastroenterology space, many services and procedures require prior authorization. The tricky thing, however, is that these requirements can change at any time — just take a look at the United Healthcare (UHC) debacle from last summer. Last June, UHC planned to implement a controversial new prior authorization policy that would require all gastroenterology physicians and patients to obtain approvals for nearly all gastroenterology procedures, including colonoscopies. After the news broke, a public outcry forced UHC to revisit the policy, and they decided to instead implement an “advanced notification” policy. 

All this to say, gastroenterology practices would like to avoid tedious prior authorization requirements whenever possible, but payers have the ability to change and evolve their policies over time, which in turn makes life more difficult for RCM teams in gastroenterology.

‍The Impact on Patients

Prior authorization requirements have a direct impact on patient care. These policies can take some time to obtain, which often delay or deter procedures. A recent study that surveyed 150+ physicians from the American College of Gastroenterology uncovered key results that demonstrate a clear impact on patient care in relation to prior auth. They found that:

1. Over 50% of respondents chose “inferior treatments” at least weekly because of a perceived prior authorization burden
2. 50% of respondents reported a patient who experienced serious adverse events due to prior authorization related care delays. 

These are serious health implications for gastroenterology patients, and could be avoided if prior authorization wasn’t so burdensome for revenue cycle teams.

The Impact on Providers

In addition to being a blocker to providing efficient care when it’s needed, prior authorization also poses financial challenges for gastroenterology providers. Because of the ever-changing rules and policies, many gastro-specific claims get denied due to a lack of prior authorization. These denials result in providers either not getting paid, or getting paid much later than they expected. For context, a study from Premier found that nearly 15% of all claims submitted to private payers are initially denied (and 3.2% of denied claims were pre-approved through prior authorization processes). With the average cost of fighting denials totaling $43.84 per claim, providers spend over $19.7 billion per year on adjudication.

These constantly changing prior authorization policies have a serious financial impact on gastroenterology practices, they are ultimately a blocker to providing best-in-class care for patients. That’s where a tool like Adonis Intelligence comes into play.

Adonis Intelligence constantly monitors your revenue cycle, and alerts you to denials and payer policy changes in real-time. Intelligence’s Smart Worklist feature categorizes adjudication tasks so that your team can see exactly why claims are being denied and which claims are impacted — giving your team the ability to predict and prevent denials in the future. 

Never be caught off guard by a change to prior authorization requirements again. Learn more.