The Importance of Collaboration Between Healthcare Providers and Payers in Streamlining Prior Authorization for Better Patient Outcomes

The prior authorization process often causes frustration for doctors and office staff. They must submit detailed medical information, follow different insurer rules, respond to denials, and check on incomplete requests. A JAMA study shows that 88% of doctors feel overwhelmed by the paperwork related to prior authorization. Sometimes, doctors spend up to two full days each week just managing these requests.

For medical offices, this means less time for patient care and more time on paperwork and phone calls.
Delays in prior authorization can slow down treatment. This can make health problems worse, cause patients to worry, and lead to more emergency room visits.
For example, urologists say delays make it harder to treat kidney stones, urinary infections, and cancers. These delays hurt patient health and satisfaction.

The rules for prior authorization differ among insurers. Doctors have to deal with many forms, documents, and deadlines.
This confusion adds more work and can also lead to doctor burnout, lowering staff morale and making it hard to keep good doctors.

The Need for Collaborative Reform

Since prior authorization slows care, payers and providers are trying to work together to improve it. They focus on several areas:

• Standardized Forms and Criteria
  Many insurers have different forms and rules. Dr. John Lam says using the same forms with clear, evidence-based rules helps cut down mistakes and extra requests.
• Real-Time Decision Making
  Waiting for prior authorization decisions causes delays. Groups like the American Medical Association want payers to respond within 48-72 hours for regular cases and under 24 hours for urgent ones. Quick decisions help doctors and patients.
• Transparency and Communication
  Doctors and patients do better when payers give clear reasons for decisions. Explaining denials and outlining next steps helps solve problems faster.
• Continuity of Care During Insurance Changes
  When patients change insurance plans, it’s important that prior authorizations still work for a short period so treatment isn’t interrupted. Payers have agreed to keep prior approvals valid for 90 days during these changes.
• Legislative and Regulatory Engagement
  Groups are pushing for laws to make sure better prior authorization processes become common. They want to balance cost control with timely patient care.
• Financial Incentives for PA Work
  There are suggestions to pay doctors for the time spent on prior authorization work. This might encourage more effort and fairness.

Examples of Progress: Industry Programs and Innovations

Some programs show how working together helps improve prior authorization:

• Health Care Service Corporation (HCSC) Augmented Intelligence Tool
  HCSC works with around 18 million members. They created a special system that speeds up prior authorization by up to 1,400 times. The tool checks old data and rules to approve simple requests almost instantly. In tests, 80% of behavioral health and 66% of specialty pharmacy requests got fast approvals.
  The tool cuts down the time to submit a request to six minutes on average. HCSC also started a “Gold Card” program. Providers who meet high standards get automatic approvals for many procedures. This program removed prior authorization for nearly 1,000 procedure codes and automatically approved over 14,000 requests.
• Highmark Health Gold Card and Active Gold Carding Programs
  Highmark’s Gold Card program rewards providers who follow guidelines 99% of the time. These providers don’t need full prior authorizations for some services, reducing admin time by up to 85%.
  The Active Gold Carding helps providers who almost qualify by giving them real-time coaching and feedback. It has expanded to over 2,800 providers, many now fully qualified.
  Highmark also uses AI and automation with partners like Abridge to offer near-instant approvals inside electronic medical records.
• Industry-Wide Commitments and Technology Standards
  More than 60 health insurers, including big groups like Blue Cross Blue Shield, agreed to use standard electronic prior authorization systems called FHIR APIs by January 2027. They aim to answer 80% of e-submitted requests in real-time.
  They also promise to lower prior authorization volume as needed, improve communication on denials, honor transition authorizations, and have licensed clinicians review medical denial cases. Federal rules support these changes.
• KLAS Collaborative Points of Light Award Winners
  Some partnerships using interoperability tools and AI have reduced prior authorization problems by up to 99%. Automation and better data sharing cut turnaround times and improved workflows, helping both providers and patients.

The Role of AI and Workflow Automation in Prior Authorization

Artificial intelligence (AI) and workflow automation are becoming important tools to fix prior authorization problems. They help reduce paperwork, speed up decisions, and improve accuracy. This leads to better care for patients.

• AI-Powered Automation of Prior Authorization Requests
  AI systems read medical records, patient history, and insurer rules to approve simple requests automatically. Systems like HCSC’s and Highmark’s use past authorizations to process requests in seconds instead of days.
• Improved Accuracy and Reduced Errors
  Linking prior authorization with electronic health records cuts down on manual errors from old fax or paper systems. This raises first-time approval rates, reducing denials and extra work.
• Real-Time Notification and Transparent Tracking
  Automation tools notify providers about prior authorization status right away. They help staff handle exceptions and appeals faster. Dashboards show pending requests and denials for better planning.
• Seamless Integration within Clinical Workflows
  Embedding prior authorization into existing electronic medical record systems makes the process smoother. Providers can submit requests without leaving their usual software.
• Reducing Provider Burden and Avoiding Burnout
  By automating routine tasks, AI cuts down on phone calls and manual steps. This helps staff avoid burnout and focus more on patient care.
• Supporting Value-Based Care and Risk-Based Models
  Fast and accurate authorizations support providers working under care models that reward good quality and cost management. Quick approvals help meet these goals.
• Standards-Driven Interoperability for Efficient Data Exchange
  Using industry standards like FHIR helps electronic health records and payer systems share data smoothly. This lowers dependence on old, slow fax or PDF submissions.

Why Medical Practice Administrators, Owners, and IT Managers Should Prioritize Collaboration and Technology

Staff who run medical practices need to fix prior authorization challenges to keep operations smooth and ensure quality care. Working closely with payers and using technology can bring benefits:

• Shorter Wait Times for Patients
  Simpler prior authorization processes let patients get care faster, which improves health and satisfaction.
• Reduced Administrative Overhead
  Automating workflows cuts down paperwork for clinical and office staff, making things more efficient.
• Improved Revenue Cycle Management
  Faster approvals and fewer denials reduce delays in billing and lost payments.
• Better Provider-Payer Relationships
  Clear and steady communication builds trust and lowers conflicts between doctors and insurers.
• Scalability for Growing Practices
  Automation helps handle more prior authorization requests without needing more staff or time.
• Regulatory Compliance and Future-Proofing
  Using electronic authorization and standard systems keeps practices in line with federal rules, reducing risks of penalties.

In summary, prior authorization should not be seen just as a barrier set by insurers. Instead, it is a shared process that needs cooperation.
Collaboration supported by new technology like AI and automation is changing prior authorization to reduce delays, paperwork, and interruptions in care.
For medical practice administrators, owners, and IT staff, learning about and using these changes is important to make work smoother and provide better care to patients across the United States.