Improving Hospital Profitability and Maximizing Patient Care with Pharmacy Management Organizations

How a well-run Advocacy and Prior Authorization Team can help profit and patients

The ultimate and most stated goal of most hospitals is to provide exceptional patient care. However, making a profit and having a consistent revenue cycle is necessary to achieve that goal. For hospitals that have specialists and infusion centers under their umbrellas, you will find that leveraging an outpatient support services function, with a focus on two key areas of

  1. Prior Authorizations
  2. Patient Financial Advocacy

you can dramatically impact both your profit and revenue cycle stability while also improving patient satisfaction and maximizing patient care.

By working within your hospital’s EMR and leveraging other forms of technology, an outsourced team that specializes in support service functions for high-cost medication scan take charge of these processes for the benefit of patient outcomes, revenues and workflows.

The Insurance Process

Many physician practices struggle with the insurance process due to the multiple aspects and layers of approval that are required after a high-cost medication is prescribed. With a high-cost impact, infusion centers can struggle to be profitable due to the lack of resources for what most would imagine to be a simple step – verifying and qualifying patient insurance. As practice managers know, the verification process consists of three components: Verification, Eligibility, and Prior-Authorization.

Let us break down each component:

Step 1: Insurance Verification

Does the patient have insurance, and are the infusion services covered under their plan? This occurs when the intake department contacts the insurance carrier (which can be time-consuming) either over the phone, through an EMR system – if offered, or through another platform like Availity.

Step 2: Eligibility

During the insurance verification process, you must also determine the plan’s eligibility period. Is the patient eligible for services during the time that you will be performing the infusion?

Step 3: Prior-Authorization (PA)

In the case of high-cost medications, it is often determined that the patient’s insurance plan requires prior authorization, which is often a burdensome and time-consuming process. According to the American Medical Association (AMA), 9 out of 10 physicians find that prior authorizations have a negative impact on patient outcomes and believe the burden associated with PAs has increased over the past five years.

This is where an outsourced support services group can step in, take charge, drive efficiency, and remove the burden from clinical staff that are better served in treating patients.

Revenue Cycle Management (RCM) and Prior Authorizations

Prior authorizations are a pain point for providers yet are crucial to the revenue cycle and clinical care operations of hospitals, infusion centers and specialty practices. With the rising cost of drugs, shrinking margins, and overall changes in the drug and healthcare industry, providers need to be sure they have a knowledgeable team that can run prior authorizations as quickly and cheaply as possible, while also sustaining a healthy revenue cycle.

A team with specific expertise on prior authorizations is ideally positioned to ensure they are approved seamlessly. These teams will know what each payer needs for each approval, and with access to the patient’s medical record, will make sure the payer has it in hand as soon as the PA is requested, so that approval is granted without delay – without needing to bother a single clinical staff member.

Everyone plays a vital role in ensuring correct reimbursement for high-cost drugs – but most organizations do not have adequate staffing or additional resources for the extensive undertaking that many prior authorizations require.

Outsourced support services exist to help practices maintain a stable and strong revenue cycle by working with the provider, the billing team, the patient, and insurance company to guarantee a seamless verification and prior authorization outcome. These types of outsourced groups, work across multiple technologies, multiple EMRs and are highly trained in the intricacies of each insurance and each medication.

Reducing Bad Debt through Patient Financial Advocacy

Once the prior authorization of a patient is received, the financial advocacy function should take over by identifying patients that are under-insured or have high out-of-pocket costs. These experts look for solutions to help patients alleviate the financial burden of their medication costs. Importantly, in cases of infusion centers, it also ensures that the provider receives payment for services delivered.

When a patient can’t afford their out-of-pocket responsibility for their medications, the prescribing physicians and their staff are often placed in a difficult situation. Many will ask their administrative or support staff to try to find a way to help the patient with their costs – but in most cases, solutions are so fragmented and clinical staff so busy, that there aren’t a lot of options. This means that there is a good chance the patient will not take the medication as prescribed. However, with an outsourced support services function, that has its finger on the pulse of all programs, all free drug options, all financial advocacy solutions and with a strong track record of helping patients find affordable solutions, the patient is alleviated of this burden. The other benefit of this, besides good patient care, is that the patient now has tremendous goodwill toward their provider for helping them find these solutions.

The Great Need for Financial Advocacy for Infusion Centers

In cases like hospital infusion centers – who don’t typically bill a patient until after the treatment – providers face a tough decision when learning that a patient can’t pay.

  1. Send the patient a constant stream of letters and notices informing them of their outstanding balance due
  2. Write-off the payment as bad debt and carry it on their balance sheet with the expectation that payment is unlikely

Patients are often unaware of the extent of their out-of-pocket expense before their treatment, and in many cases, even if they are aware, are unable to afford them.

Improving Cash Flow Management

Most hospitals will bill insurance on a regular basis to ensure ample cash flow and will proactively send out a series of notices to patients to settle outstanding accounts. In these notices, the patient is instructed to submit payment within a given timeframe. If payment is not received, the provider will send the patient to collections (likely lowering patient satisfaction scores). This is really the only process that a hospital must collect monies owed, yet it is inefficient and usually unsuccessful.

There is a Better Way

There are many ways to avoid the ‘bad debt’ cycle that a hospital (and your patients) might find themselves in, particularly when helping patients cover their infusion and in-office drug costs. By taking advantage of many of the manufacturers, foundation, and non-profit support programs, it is likely that your patients will be able to find the help they need to cover their out-of-pocket costs.



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