Why should healthcare providers automate their prior authorization (PA) process, and why should insurers and policy makers take actions to substantially reduce how often PA is required?
Because it’s medically necessary.
It’s necessary for providers, who spend roughly 13 hours per physician each week on PA tasks such as navigating insurance requirements, submitting forms, appealing denials, and participating in peer-to-peer reviews with health plan representatives. PA reduction andautomation will give clinicians more time with patients.
It’s necessary for patients, who often abandon care or experience worse health outcomes because of delays and denials. Arecent survey found that 16% of all insured adults experience PA problems. PA reduction andautomation can help improve patient outcomes.
And it’s necessary for hospitals and other healthcare providers, which are spending $10 billion on the PA process each year. PA reduction and automation will reduce administrative costs, lower other administrative burdens, and improve cash flow.
Tackling the PA paradox
Payers created the PA process in the 1980s and 1990s as a cost containment effort, to validate that services being ordered by healthcare providers were medically necessary. Payers felt they needed PA because a handful of bad actors frequently referred patients for inappropriate care.
The goals had value, but here’s the paradox: The PA process has become so bureaucratic, burdensome, and ubiquitous that it often leads to higher overall costs and denial or delay of appropriate care.
A big fix would be to narrow PA use to a much smaller number of providers and treatments. In recent years, we’ve seen incremental progress. Some payers are starting to roll back PA requirements. A handful of states have passed “gold card” legislation that exempts physicians with good track records from PA requirements on specified services.
But there’s still a long way to go. PA use remains toobroad. Gold card laws have not yet proven as effective as hoped, and similar federal legislation stalled. Payers’ use of AI-driven automated decision-making,which could provide greater efficiency, may instead be increasing the number of unwarranted denials. (If so, the problem is likely related to the parameters that payers are giving to AI and their overzealousness in cutting humans out of the process — factors that I’ve warned can create problems.)
But for healthcare providers looking to reduce their PA pain, here’s some good news: You can obtain a lot of pain relief on your own. How? With your own automation of the process.
Why and how providers should automate their PA process
Obtaining prior authorization has become very complex. Patients use different insurers and plans. Many of these insurers and plans differ in their approval criteria for authorizing a test or treatment. They also may use different electronic systems or phone and fax processes. That’s a lot for clinicians and staff to sort through manually.
Consider your existing PA process. Are there frequent delaysin the process? Are workflows standardized or do they vary by department orpayer? How, if at all, is the process automated?
With automation, including the careful inclusion of AI, healthcare system administrators can alleviate PA process complexity. You can use software and technology to:
Digitize the PA process by integrating electronic health records, insurance information, and clinical decision support tools.
- Digitize the PA process by integrating electronic health records, insurance information, and clinical decision support tools.
- Automatically check clinical guidelines, insurance coverages, and other relevant information to determine whether a medical service, test, or medication requires PA.
- Automatically submit the PA request. Often, the system will be able to retrieve and provide an answer in seconds. Alternatively, the system will notify the provider that the request has been received and is under review.
I realize that automation by providers isn’t a cure-all for what ails the PA process. But I can say from experience that the return on investment is still substantial in terms of the benefits for clinicians, patients, and administrators.
Best of all, modernizing PA on the provider side is an action you can take on your own, deciding what’s in your best interest. To automate and reap the rewards, you don’t need prior approval.
