Implementing a standardized process to improve insurance pre-authorization time and subsequent delays in care

Date

2023-08

Authors

Davis, Vernice

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Abstract

Background: Lack of standardization in pre-authorization processes by insurance companies has resulted in inefficiencies and delays, causing fiscal consequences and adverse impacts on patient care in various healthcare settings related to delays in care. Purpose: This quality improvement (QI) project aimed to establish, educate, and implement a standardized process for pre-authorization claims to improve knowledge of a standardized process and reduce claims decision turnaround times (TATs). Design & Methods: A standardized process was developed and implemented over a 12-week period. Nine participants received education on the required procedures for processing insurance claims. Knowledge was evaluated using a pretest-posttest design. TAT was evaluated with an existing measurement application. Results: Knowledge test scores showed a significant improvement from pre-test to post-test. A steady rise in TAT was observed. Conclusion: Future QI projects should focus on enhancing insurance pre-authorization time and reducing patient delays in care through implementing standardized processes, education, standardized process protocols, and policy changes. By considering the sustainability of these projects and incorporating continuous evaluation, stakeholder engagement, education, policy advocacy, and long-term planning, organizations can achieve lasting improvements in turnaround times and ultimately provide patients with more timely and efficient care. Keywords: utilization management, prior authorization, insurance claims, systemic review of insurance authorization.

Description

A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice.

Keywords

insurance authorization, insurance claims, preauthorization, prior authorization, systemic review of insurance authorization, utilization management

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