From insurance notifications to prior authorizations: Streamlining processes to empower nurses and enhance patient care
During times of ongoing healthcare staffing shortages, today’s nurses face unprecedented pressure in the workplace. Although longer-term staffing projections look favorable, scarcity of nurses will likely continue in the short-term. Nationally, there is a projected shortage of 78,610 full-time equivalent (FTE) RNs in 2025 and a shortage of 63,720 FTE RNs in 2030. As healthcare organizations try to meet patients demands using existing resources, nursing burnout continues to increase. Unfortunately, the dangers of nurse burnout are dire: Lower healthcare quality and safety and lower patient satisfaction. This is the antithesis of what nurses want. They entered the nursing profession to take care of patients—not harm them.
It's against this backdrop that many of today’s nurses also face another challenge compromising their ability to care for patients efficiently and further exacerbating burnout: Prior authorizations.
Consequences of medical prior authorization delays
Physicians and their staff (nurses included) spend 12 hours each week completing prior authorizations. This is time that they could otherwise spend caring for patients directly. In addition to the time spent, there’s also the added stress of waiting for payers to respond. For nurses, there’s nothing more frustrating than knowing what a patient needs and not being able to give it to them because of delays related to insurance approval. In healthcare, every minute—and even every second—counts. Medical prior authorization delays can be deadly.
More than half (55%) of physicians say prior authorization delayed care ‘always’ or ‘often.’ And when prior authorization denials occur, 48% of physicians don’t appeal the denial because they say patient care cannot wait for the health plan to approve the appeal. The effects of these delays is perhaps most profound in cancer care. Nearly a third of radiation oncologists (30%) say prior authorization delays caused adverse events including emergency room visits, hospitalization, or permanent disability for their patients. Seven percent report that delays led or contributed to the death of a patient in their care.
How to fix nurse burnout: Empowering nurses in the workplace to obtain timely prior authorizations
As healthcare organizations examine how to fix nurse burnout and promote nurse empowerment, establishing a seamless process for prior authorizations and other important insurance notifications can be helpful. Consider the following four strategies for empowering nurses in the workplace:
1. Leverage a team-based approach. To streamline prior authorization efficiency, healthcare organizations must ensure open lines of communication between revenue cycle management and clinical teams. The goal is to ensure information flows seamlessly between key stakeholders and prevent instances of prior authorization delayed care.
Efficient prior authorization starts with efficient provider credentialing and enrollment—a time when organizations ensure that providers meet specific qualifications and standards to treat patients and register with payers to receive reimbursement. Provider credentialing and enrollment lays the foundation for every subsequent step in the revenue cycle, including the ability to obtain prior authorization.
Next, collecting accurate patient demographic and insurance information as quickly as possible allows revenue cycle management staff to promptly identify whether a payer requires prior authorization for the service or medication. Communication between revenue cycle staff and nurses regarding payer-specific documentation requirements for prior authorization can expedite the process. This includes notifying nurses immediately of new prior authorization requirements, medical coding updates that could affect prior authorization, and other information necessary to obtain the prior authorization as quickly as possible and prevent the need for an appeal. Empowering nurses in the workplace means giving them the information they need to be successful.
2. Say goodbye to manual processes. If an organization still relies on fax or phone to obtain prior authorization, electronic upgrades are essential. Electronic prior authorizations not only speed up the entire process; they also reduce errors inherent in manual processes (e.g., spelling mistakes, leaving fields blank, or failure to follow payer requirements). Organizations can support nurse empowerment by giving nurses access to the right technology.
3. Track and trend prior authorization-related denials. Expediting the prior authorization process means knowing why payers tend to deny prior authorization—and implementing proactive processes to avoid those denials. This requires transparency, communication, and collaboration.
4. Provide ongoing education. As prior authorizations become increasingly complex and nuanced, healthcare organizations must educate staff to ensure compliance. This includes educating everyone who plays a role in prior authorizations-related workflows such as provider credentialing and enrollment, registration staff, medical coders and billers, nurses, clinical documentation improvement specialists, physicians, and others.
Looking ahead: Nurse empowerment and prior authorizations
In terms of how to fix nurse burnout and reduce the dangers of nurse burnout, creating interconnected workflows is particularly important. However, proactive denial management, education, and technology also play critical roles. Learn how Inland RCM can help.