Effective Prior Authorization Strategies for Faster Approvals and Improved Patient Access

The 2023 American Medical Association (AMA) prior authorization physician survey is a wake-up call for the healthcare industry, given its telling facts. The nationwide survey of 1,000 practicing physicians reported: 

1. Around 94% of respondents citing pre-authorization resulting in care delays 
2. About 95% of respondents expressing prior authorization-related burnout 
3. 1 in 4 physicians reporting related payer denials 
4. Many reporting to spend over 12 hours weekly completing prior authorization  

These findings underscore the substantial administrative burden the process imposes on physicians, taking away their valuable time from patient care, costing them monetarily, and contributing significantly to their burnout.  

What is prior authorization and how it is critical to patient access and revenue cycle management (RCM) 

Prior authorization is a routine front-end medical requisite requiring providers to obtain payer approval on recommended treatment, drugs, and services before delivering care. It is also one of the most critical steps at the front end of RCM. Despite its criticality in ensuring cost-effective, medically necessary care, the process is often a cause of a headache and bottleneck for healthcare providers.  

Complex policy-driven payer requirements and the high administrative burden for providers make prior authorization time-consuming and prone to errors, resulting in treatment delays and, sometimes, abandonment, frustrated patients, and underutilized clinical staff. This further impacts both clinical and financial outcomes for providers.  

Strategic refinement of prior authorization is the need of the hour 

Streamlining this process, thus, becomes crucial for providers to improve patient access and experience, as well as the financial health of their practice. With providers already struggling to stay solvent given their dwindling margins, rising prior authorization complexities can cause additional setbacks. But they needn’t worry – this blog offers foolproof strategies to effectively manage prior authorization for faster approvals and improved patient care and RCM.

Key strategies for effective prior authorization 

1. Putting effective SOPs and project management in place: To boost staff productivity and efficiency, it’s important to have standard operating procedures (SOPs) related to prior authorization tasks, outlining each phase clearly from documentation to approval. Having defined SOPs on pre-auth tasks helps keep the staff members updated on the entire process and their responsibilities, aligning them well to support other related operations to facilitate smoother patient access. Additionally, having a project management team in place to support the process can help do away with unnecessary confusion and delays with immediate query and problem resolution, quickening the process for approval and care delivery.  
2. Harnessing automation: Harnessing electronic prior authorization tools to automate repetitive tasks can help minimize paperwork, staff burnout, and operational costs while improving process efficiency and productivity through digital submissions and request monitoring. Integration of these tools with EHRs can help reduce manual errors substantially and expedite the process with the quick submission of accurate, error-free documentation and the real-time tracking of requests, thus eliminating unnecessary delays. Besides, such tools help in efficient data sharing and removal of duplicate data entries.  
3. Enhancing communication: It’s important for providers to nurture payer relations to keep the process streamlined. They must maintain transparent communication with the payers, understanding their needs and approval requirements. Moreover, they must communicate over secure channels for the safe exchange of sensitive patient information. In addition, they should inform patients of potential setbacks and their financial responsibility before proceeding with the process. 
4. Tracking key performance indicators (KPIs): Providers shouldn’t shy away from using advanced technologies like artificial intelligence (AI) and business intelligence (BI) to monitor prior authorization-related KPIs, like the time taken to get payer approvals and the denial rate related to the process, through intelligent dashboards. This makes it easier to identify systemic loopholes and take timely corrective measures to seal the gaps. This further helps boost process efficiency to speed up approvals and improve care delivery and the revenue cycle. 
5. Standardizing documentation: Standardization of documentation needed for payer approval is key to streamlining prior authorization, and partnering with reputed prior authorization companies can greatly help providers lacking the required expertise. Such companies are well-versed with changing payer needs and policies and can help providers navigate documentation complexities with ease. By ensuring necessary information in submissions as per regulatory and payer policies, they can help secure timely approvals to facilitate patient care.