Patient Access Challenges in Healthcare

Patient access functions are a critical component of optimizing revenue cycle management (RCM) processes. While patient access teams have always faced operational hurdles, these challenges have grown more evident due to increasingly complex payer requirements, labor shortages, and more extensive administrative workloads. Effective workflows require the ability to follow financial clearance processes to track authorizations, verify eligibility and benefits, and identify at-risk accounts for immediate attention. Inefficiencies in these efforts are resulting in increased front-end denials, claim rework, and lost revenue, which can impact patient care, staff morale, and retention rates.

Key challenges faced by patient access teams include:

1. Increased Administrative Burdens

   Patient access teams are increasingly overwhelmed by administrative tasks, such as prior authorizations and financial clearance processes. Front desk employees are spending more time on these tasks, leaving less time for patient-facing interactions. This shift not only affects patient care but also contributes to staff burnout and high turnover rates. The complexity of prior authorization requirements and overall volume of prior authorizations has grown significantly. Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023, an increase of 8 million over 2022 and 13 million over 2021 as Medicare Advantage enrollment has risen.

2. Fragmented Workflows and Siloed Teams

   Decentralized patient access models have the potential to result in disconnected processes, creating barriers to efficient scheduling, eligibility verification, and prior authorization. These fragmented workflows lead to increased front-end denial rates, financial losses, and patient dissatisfaction. Studies show that nearly 50% of denials can be traced back to front-end revenue cycle issues, such as inconsistent processes that delay reimbursement and require extensive claims rework.

3. Technology Gaps

   A reliance on outdated systems and manual processes and lack of advanced technology tools creates inefficiencies in patient access workflows. According to a recent AGS Health survey on the state of patient access, nearly half of the respondents indicated that no automation had been implemented to support patient access processes, while less than 10% had implemented automation for insurance eligibility and benefits verification.

   

4. Evolving Payer Requirements

   Frequent changes by payers to prior authorization rules result in rigorous documentation requirements, leading to incomplete or inconsistent documentation, compliance issues, and increased denial rates. Additionally, payers are using advanced technologies to automate medical necessity reviews, creating additional rework for hospital and health system staff when authorizations for procedures are denied. These issues are complicating the ability to streamline workflows and effectively manage staff time and resources, impacting eligibility and benefits verification, and prior authorizations.

5. Workforce Shortages

   The healthcare industry is facing a chronic shortage of skilled RCM professionals, including patient access staff. High turnover rates necessitate constant training and retraining of new team members, adding to operational inefficiencies. This shortage is compounded by the increasing administrative burden, leaving patient access teams stretched thin and struggling to meet growing demands.

6. Lack of Analytics and Reporting Flexibility

   Inflexible analytics and reporting systems can hinder effective performance monitoring and root cause analysis. Many healthcare organizations lack the insights to identify and remediate systemic issues undermining patient access and financial clearance operations. Nearly 30% of survey respondents to the AGS Health survey on the state of patient access indicated that their current systems lacked the ability to drill down into trends, preventing organizations from identifying systemic issues and implementing targeted solutions.

Addressing these challenges requires a strategic approach that streamlines workflows, implements advanced analytics, and leverages automation tools to reduce revenue cycle operating costs. Download our white paper, "Transforming Patient Access: A Practical Guide to Maturity," for a detailed roadmap and actionable strategies to overcome patient access challenges and optimize your revenue cycle management. Stay tuned for our next article in the series that shares a stepwise approach to centralization for patient access.