CHICAGO—One of New Jersey’s largest hospital groups has automated more than 60% of its prior-authorization workflows in radiology, turning a once-chaotic process into a fine-tuned machine.
Atlantic Health System is a vast enterprise that includes seven hospitals, 23 urgent care centers, and a multi-specialty practice with 1,000-plus physicians and other providers. The organization has faced heavy demand for imaging, coupled with a fractured approach to obtaining prior authorization from payers, leaders told attendees at the HIMSS23 conference on Tuesday, April 18.
Each practice had its own responsibility to gain prior approval for imaging. Technology varied from one location to the next, and Atlantic Health had “absolutely no metrics” to track and improve processes.
“There was often a lot of manual payer follow-up,” Danielle Pieloch, executive director of patient access at Atlantic Health, told attendees. “It always pains me to walk around this area and see my team members wasting their time waiting on hold.”
“We really had a lot of duplicative efforts between our medical group and our hospital division,” she added later.
But beginning in May 2021, Atlantic embarked on a systematic process to streamline how it obtains payer authorization for imaging. Using collaboration across teams and automation, Atlantic has seen a more than 50% reduction in the time it takes to submit a request, falling from 18-22 minutes down to 7-10 minutes. Pieloch and colleagues have been able to achieve more than 60% automation of the prior authorization workflow in radiology and 65% reduction in the processing time. And they’ve cut the cancelation rate due to denied or delayed exams to an average of less than 2% after it had once approached 4%.
“We really took a detailed look at that workflow, what our practices were doing and what we were doing [on the hospital side],” Pieloch said. “Instead of having two completely different process maps, we threw them in the garbage and came up with one that was streamlined between our physician practices and our hospital group.”
To begin addressing the issue, Atlantic Health created a centralized team to handle prior authorizations. This included redesigning job descriptions, evaluating salaries, providing training around new productivity standards and implementing a hybrid work program. Then, leaders implemented a standardized workflow with escalation protocols for more urgent exams, communication training and the elimination of redundant steps. Finally, they’ve sought to better measure performance around patient outcomes and productivity, among other things.
IT experts have used a mix of robotic process automation, AI and machine learning to fuel the new prior authorization process. Following the changes, Atlantic now schedules imaging appointments first before seeking payer authorization, rather than the other way around. Employees no longer need to waste time on exams that do not require approval, and the submission of requests to insurers is automated from the EHR using already-available data. “Intelligent automation” now verifies requests and updates information accordingly, eliminating any need to check payer portals or call on the phone for updates.
The new process has helped Atlantic Health to increase the average lead time for starting authorizations by eight days, whereas in the past, employees sometimes were chasing approvals at the last minute.
“This team historically, because of all the manual work, they were scrambling a lot of times looking to ready accounts for the next day or the day after, instead of working far out into the future” Pieloch said. “Which obviously, from a patient and physician satisfaction standpoint, is not ideal.”
Atlantic believes the effort has been crucial to help spur its growth initiatives and better compete with the many freestanding radiology service groups in its markets, she added.
Leaders hope to expand this initiative to other specialties including cardiology. They offered six lessons learned from the process:
- Automation alone may not give us the desired outcome. Workflow optimization and review of the current processes should be considered as prerequisites for a successful automation initiative.
- Including key stakeholders from all the affected areas early in the project is important.
- Patient access-driven initiatives can have significant impact on physicians’ workflows.
- Communication and training in all areas should be considered as an integral part of the project plan.
- During the technical analysis, look at each system and identify new interface needs early in the process to avoid any potential delays.
- Do not expect perfect outcome and continue to optimize post-live.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.