Electronic Health Reporter

By Matt Bridge and Ryan Chapin of AGS Health 

The prior authorization process has evolved in complexity as the healthcare industry transitions from fee-for-service to value-based care. At the same time, payers are expanding the number of services subject to prior authorization to establish medical necessity and appropriateness. It’s a one-two punch that leaves providers and provider organizations struggling under the weight of a prior authorization burden that, left unaddressed, can have long-term revenue cycle impacts.  

Today’s prior authorization process involves time-consuming steps, including gathering and submitting medical documents to insurance companies and waiting for approval. It also often involves dealing with denials and appeals – all while guidance around required documentation becomes stricter.  

The number of procedures subject to authorization is also expanding, creating new challenges for staff who must understand the clinical documentation and office notes necessary to support the authorization. This also means the addition of new administrative requirements with far-reaching impacts on finances, operations, and patients. Additionally, when establishing a centralized prior authorization team is infeasible, expanded prior authorization needs exacerbate the problem of competing priorities for staff tasked with obtaining authorizations amidst other core responsibilities, including patient care. 

Prior Authorization Challenges  

The impact of today’s challenging prior authorization environment is felt in three key areas:  financial, operational, and the patient experience. 

On the financial front, the administrative burden of prior authorization has increased steadily over the years, leading to additional costs and workload. Among the most significant financial impacts are higher administrative costs and reduced or lost revenues due to denials, which can be difficult to overturn. The prior authorization process can also delay cash flow. 

Operationally, the increased time and effort required to manage prior authorization is a resource drain that pulls staff away from other important tasks, including patient-facing activities. It also increases the workload of revenue cycle management (RCM) staff, leading to burnout and staff turnover. For example, absent a dedicated prior authorization team, front desk staff are often charged with obtaining prior authorizations in addition to their patient responsibilities.  

The complexity of the prior authorization process can also negatively impact patient satisfaction and quality of care. Not only is it confusing and frustrating for patients, but it can create delays in care that can lead to avoidable health outcomes. It can also create an unexpected financial burden when a prior authorization request is denied – a burden that can sometimes result in the patient refusing needed care. 

Pain Relief Strategies 

Alleviating the headache created by these negative impacts calls for a “people, process, technology” approach that combines workflow optimization, streamlined processes, and advanced technology tools that work together to reduce the burden of prior authorizations. 

One of the most critical steps for navigating the prior authorization process is optimizing and developing workflows that benefit providers’ bottom line. This includes ensuring the right resources are in place to create a high-performing prior authorization team capable of efficiently managing the prior authorization process.  

Centralized teams are typically most effective and can be successful via any of the following models: 

• In-house (least cost-effective): Sourcing in-person or virtual support from the U.S.  
• Outsourced (most cost-effective): Sourcing virtual resources from countries outside the U.S. 
• Hybrid (cost-effective): Utilizing a combination of onshore and offshore resources. 

Another key strategy is to standardize processes for prior authorization workflows to ensure accurate and consistent outcomes. Providers should also work closely with payers to understand the prior authorization requirements for each and track the status of requests to ensure that they are approved in a timely manner. 

Leveraging technology can significantly improve the efficiency and accuracy of the prior authorization process. Automating certain aspects of the process using generative artificial intelligence (AI), advanced bots, or intelligent automation tools can reduce workloads, allowing staff to focus on more critical tasks while minimizing the risk of errors. It can also reduce manual touches and increase staff efficiency.  

Finally, utilizing predictive analytics to identify trends and patterns in prior authorization denials and rejections enables necessary process adjustments.  

 Simplifying the Process 

The increasingly complex prior authorization environment does not have to mean a permanent migraine for healthcare organizations. With the right strategies and tools in place, providers can stay ahead of the changes and accelerate and streamline the prior authorization process, improving efficiencies and reducing staff burden and burnout – all while ensuring patients receive the care they need in a timely manner.