Back in 2018, a group of organizations issued a consensus statement that targeted the need and the goals for improving the prior authorization process. These organizations and their leadership, consisting of physicians (AMA, MGMA), pharmacists (APhA), hospitals (AHA), and insurance payers (AHIP), agreed to take a collaborative approach to improve the prior authorization processing system industry-wide.

Revisiting this issue in May, 2021, and pointing to the AMA survey from December 2020, we find that 83% of respondents still indicate that prior authorizations have increased over the last five years. Observing the progress made is less than satisfying and it may not change significantly any time soon. While there is a strong payer commitment to prior authorizations improvement with 96% of payers stating they are in a cooperative stance, an ever-increasing number of providers say the burden has only grown.

Can Automating Prior Authorizations be a Solution?

To state clearly, according to the MGMA 2019 survey, 90% of responding providers said that the prior authorization burden has grown in the last year. On the flip side, as many as 88% of prior authorizations are completed (either partially or entirely) using a manual workflow. This means untold hours of hold times, faxing, and follow-up that equates to an average of 14.9 hours (or two business days) per provider.

What’s to be Gained?

By introducing automation to the prior authorization process, hospitals and providers stand to gain exponentially in terms of the following:

  • Reduced patient frustration and potential abandonment of care
  • Administrative focus moved from payer prior authorization regulation compliance to patient experience and higher value efforts
  • Significant reduction in claim denials
  • Increased revenue and operational bottom-line results
  • And maybe most importantly, reduced physician burnout and early retirement, and increased interest in healthcare provider career options to combat the severe shortage materializing currently

How Does Automation Change the Prior Authorization Process?

When examining the administrative workflow, it becomes clear that Artificial Intelligence (AI) and machine learning software can actively absorb much of the routine, repetitive functions when filtered through a continually expanding clearinghouse of payer criteria. Ideally, the process would advance as such:

  • Once a patient’s treatment plan and payer eligibility has been gathered and verified, a needs determination would assess insurance requirements.
  • If a prior authorization is required, automated submission would be initiated and followed-up through a bi-directional, seamless portal integrated with the provider’s EHR/EMR system.
  • Scheduling personnel would be notified electronically when the prior authorization was approved reducing the need for rescheduling and inconveniencing patients.
  • Automated follow-up and status checks in real-time would ensure no patient falls through the cracks.
  • And because AI isn’t an end-all solution nor does it operate in a vacuum, certified specialists (human intelligence) would actively engage and submit prior authorization requests that were emergent or needed special handling.

While the wheels continue to grind on healthcare prior authorization reform, let’s not forget that the primary reasons that utilization management and prior authorizations were instituted are still very valid and worth pursuing — solid, necessary medical care that is cost-effective. By removing the administrative burden, as well as the feeling of having to ask for permission, through automation and real-time approvals, providers and patients can focus on the healthcare decisions that are the reason for the process in the first place.

Contact us to request a demo to discuss state-of-the-art AI-driven prior authorization technology and support, as well as expert certified specialists.