MetroHealth Achieves 173% Surge in Prior Authorizations with Experian Health Automation

CLEVELAND – MetroHealth, a leading healthcare system serving over 300,000 patients annually, has dramatically improved its prior authorization process, boosting monthly transactions by 173% and freeing up critical staff time. The transformation, detailed in a new case study, was achieved through the implementation of Experian Health’s Authorizations solution, addressing a growing bottleneck in patient care and revenue cycle management.

The Prior Authorization Crisis: A Healthcare System Under Strain

Prior authorization – the process of obtaining approval from insurance companies before certain medical procedures or medications can be administered – has become a significant pain point for healthcare providers nationwide. Manual processes, characterized by phone calls, faxes, and navigating complex payer portals, consume valuable staff time, delay patient care, and contribute to administrative costs. The sheer volume of requests, coupled with increasingly stringent payer requirements, has created a crisis for many organizations.

For MetroHealth, this crisis manifested as overwhelmed teams, appointment delays, and a growing risk of claim denials. Staff were spending an inordinate amount of time chasing approvals, leaving less time for direct patient care. The existing manual workflows simply couldn’t scale to meet the demands of a growing patient population. This situation isn’t unique to MetroHealth; a recent report by the American Medical Association highlights the escalating burden of prior authorizations on physicians and their staff. Learn more about the AMA’s findings here.

Seeking a Solution: Automation as the Key

Recognizing the unsustainable nature of the manual process, MetroHealth sought a partner capable of handling their high authorization volumes and reducing reliance on time-consuming tasks. The ideal solution needed strong payer connections and robust automation capabilities. Experian Health’s Authorizations platform emerged as the clear choice.

Automated Efficiency: How it Works

Experian Health’s Authorizations solution automates the entire inquiry and submission process. When a physician places an order within the Epic electronic health record (EHR) system, the authorization process initiates automatically. The system captures payer details and submits the request in seconds, providing real-time updates directly within the EHR. This eliminates the need for staff to manually enter information or track down approvals.

A key differentiator is Experian Health’s extensive network of payer connections, including major players like UnitedHealthcare, Aetna, Humana, Cigna, eviCore, AIM, and NIA. This ensures that requests are routed to the correct payer partner, accelerating determinations and keeping care on schedule. The platform also streamlines the process by handling a wide range of authorization types through a single, unified workflow.

Furthermore, the solution’s Knowledgebase feature provides staff with access to a continually updated library of payer rule sets, minimizing errors and ensuring accuracy. Custom rules can be added to address unique requirements, giving MetroHealth greater control over the authorization process.

Transformative Results: A Data-Driven Success Story

The implementation of Experian Health’s Authorizations solution yielded remarkable results for MetroHealth:

• Authorization Volume: Monthly transactions increased by 173%, soaring from 2,200 to 6,000.
• Time Savings: Teams now work 30 days ahead of scheduled services, a 114% increase in available time.
• Efficiency Gains: Average time spent on each authorization request plummeted from 10 minutes to under 4 minutes.
• Faster Follow-Ups: Follow-up processes are now 50% faster.
• Expedited Reviews: Peer-to-peer reviews are completed 4-5 days sooner.

These improvements translate to significant benefits for both staff and patients. Instead of being bogged down in administrative tasks, staff can focus on providing high-quality patient care. Faster authorization times mean patients receive the treatments they need more quickly, improving outcomes and satisfaction. What challenges do *you* face in managing prior authorizations at your organization?

The increased capacity also allowed MetroHealth to support more service lines and higher patient volumes without the need for additional hiring. The system’s ability to capture required details and keep requests moving has proven invaluable.

On the clinical side, the 60% reduction in time spent on authorizations and faster peer-to-peer reviews have a direct positive impact on patient care, allowing clinicians to focus on what they do best: treating patients.

Key Takeaways: Building a Sustainable Authorization Process

MetroHealth’s success story underscores the importance of creating a streamlined and efficient authorization process. The management team identified three key factors that contributed to their success:

• Stakeholder Alignment: Bringing the right people to the table from the outset to ensure everyone was aligned on the workflow and goals.
• Data Accessibility: Making critical data easily accessible, such as integrating CPT codes directly into the system.
• Ongoing Training & Communication: Investing in comprehensive training and ongoing communication to ensure staff understood how to use the solution effectively.

Did You Know?

Frequently Asked Questions About Prior Authorization Automation