Prior authorization often needs clinical and administrative staff to do many time-consuming jobs like faxing forms, making phone calls, and sending emails to insurance companies. These tasks usually take between 16 and 40 minutes each, with an average of about 24 minutes per request. Sometimes, staff spend 12 to 14 hours every week handling these tasks, according to surveys by the American Medical Association. This heavy workload causes staff to feel burned out, leading to lower morale and more people leaving their jobs.
Burnout happens mostly because staff must do the same hard tasks over and over without much variety or satisfaction. Wayne Carter, an expert in managing money flow for medical practices, calls staff burnout a “silent disruptor” for prior authorization work. It causes more mistakes, missed deadlines, and poor communication between departments. Burnout also lowers productivity and makes more staff quit, so clinics have to spend more time and money training new workers. This puts more strain on already limited staff.
Managing a fast and accurate prior authorization process manually, especially with many requests, causes big pressure on healthcare teams. Reports say 37% of prior authorization tasks struggle because of staffing problems, which cause errors and delays. These issues lead to submitting forms with mistakes, resulting in resubmissions and appeals that waste even more time and money.
The money cost of manual prior authorization is higher than just staff time. Studies show that manual prior authorization costs the U.S. healthcare system about $35 billion a year. This includes labor costs, denied claims, delayed payments, and other administrative expenses. Each manual prior authorization costs roughly $3.41 on average, though some say it can go as high as $11 per request.
These costs grow bigger when considering claim denials and payment delays. If prior authorization is not done correctly or on time, providers often have claims denied or delayed. For example, in certain surgery departments, prior authorization denials make up 16% of all claim denials. This causes millions of dollars lost. One hospital’s surgery department reported over $21 million in denied charges and nearly $300,000 in unpaid revenue due to prior authorization problems in a single year.
Denied claims keep money owed to providers from coming in quickly. This harms cash flow, which is needed for smooth healthcare operations. Revenue lost from denials also means costly extra work like appeals and resubmissions. Specialties with many cases, like cardiology, oncology, and radiology, face even harder authorization rules that make these problems worse. For them, automation and special support are very helpful.
Delays in prior authorization also cause indirect money problems. Doctors and healthcare teams spend lots of time on these requests instead of caring for patients. The cost of extra administrative work can be about $82,000 each year for every physician. This shows the need for faster and easier systems.
Prior authorization is supposed to help control costs and make sure treatments are necessary before they happen. But the current manual system often causes problems for patient care. According to the American Medical Association, 94% of doctors say prior authorization delays hurt patient care. Also, 78% of doctors say patients stop their prescribed treatments because of these delays.
These delays do more than annoy patients; they make health outcomes worse. Studies show prior authorization causes about 69% of cases to have weak initial treatments because of rules like step therapy and insurer limits. Patients end up needing more office visits, emergency room trips, and hospital stays due to these hold-ups. For example, 42% of doctors said prior authorization delays led to emergency visits, while 29% said these delays caused hospital stays.
Patients often pay extra costs because of prior authorization issues. About 79% of doctors said patients have to pay out of their own pockets for medications delayed or denied by prior authorization. This can cause financial hardship for patients and make them lose trust in healthcare.
Employers also see effects from prior authorization delays. More than half of doctors say these problems hurt workers’ job performance, leading to lost productivity and more missed workdays.
Manual prior authorization uses old technology and disconnected systems. Only 28% of these requests are processed fully electronically. Most still rely on faxes, phone calls, and typing in data by hand. This lack of automation causes slowdowns during steps like scheduling, insurance checks, documentation, coding, billing, and handling denied claims.
Frequent changes in insurance rules make this harder. Staff must keep up with many complex and changing policies. Without real-time connections between office software, electronic health records (EHRs), and insurance systems, the tasks are hard and mistakes happen easily.
Staff have to manage many separate systems and communication ways. This leads to duplicated work, delays, and risk of incomplete or wrong claims. These problems raise the chance of claim denials, slow down money coming in, and frustrate healthcare providers.
New advances in artificial intelligence (AI) and automation offer ways to fix the problems of manual prior authorization. AI software and automated workflows greatly lower the work needed from healthcare staff while making the process faster and more accurate.
For example, AI systems like Simbo AI’s SimboConnect Voice AI Agents handle front office phone calls for prior authorization. They work around the clock, including after hours, letting staff focus on more important clinical and office work while keeping good communication with insurers and patients.
AI automation can process prior authorization requests up to 10 times faster than manual methods. Tools like Thoughtful’s PAULA have a 98% success rate on first try by automatically sending requests, checking insurance info, and adjusting to insurance rules. These tools can also create appeals with clinical evidence, reducing manual work and improving chances of approval.
Automation also lowers costs. It drops the cost per request from about $3.41 to just five cents—a savings of over 98%. It saves around 14 minutes per request, adding up to thousands of staff hours saved every year. For example, Highmark Health automated over 2 million COVID-19 claims, saving 180,000 staff hours and speeding up claims.
This automation helps with managing money flow by cutting denials and extra work. Schneck Medical Center saw a 2.5% rise in approved outpatient visits after adding AI prior authorization, without needing more staff. Fresno Healthcare cut denial rates by 22%, helping them collect revenue faster and improving cash flow.
Integration with EHRs and practice software makes the process easier by automatically filling authorization forms with correct patient and clinical data. This reduces errors and meets insurance and legal rules, such as CMS’s required electronic prior authorization standards using HL7 FHIR API. These standards will be fully in place by 2027, and healthcare groups are preparing now to meet them.
AI and automation also help reduce staff burnout by removing boring, repeated tasks. This lets employees do more meaningful work. Lower burnout means fewer people quit, better staff retention, and smoother operations in busy practices.
By checking how workflows currently operate and watching key numbers like turnaround time, approval rates, and how often requests must be redone, healthcare groups can make smart automation decisions. Working with certified prior authorization service providers, especially those who know high-volume specialties, can improve the process further.
Manual prior authorization takes a lot of time and resources and affects patient care, staff well-being, and healthcare costs. As costs rise and rules get more complex, relying on manual methods becomes harder to keep up with.
Healthcare providers across the U.S. are starting to use AI and automation to solve these problems, improve workflows, reduce burnout, and get more revenue. Moving to automated prior authorization is a practical way to update healthcare management and support long-term success.
Medical practice administrators, owners, and IT managers are encouraged to consider AI-powered prior authorization tools like those from Simbo AI and others. They should choose solutions that integrate well, grow as needed, and save time and money without hurting patient care. With healthcare getting more complicated, automation helps organizations get better financial and clinical results in the future.
The front-end of the revenue cycle includes non-clinical processes before patient care, such as scheduling, verifying insurance eligibility, obtaining prior authorizations, and collecting co-pays. These steps ensure claim accuracy and smooth billing downstream.
Prior authorization is crucial to ensure treatments or medications are needed and covered by insurance. It prevents claim denials, financial loss, and unnecessary costs by verifying coverage before care delivery.
Common pitfalls include incorrect patient insurance information, inefficient manual operations, outdated payer requirements, and incomplete authorizations. These issues cause delays, increased denials, and added administrative burdens.
Automation enhances accuracy and efficiency by digitally managing data entry, submitting requests, and tracking status. It flags requirements early, reduces manual errors, and speeds up the entire prior authorization workflow.
Benefits include massively reduced costs and processing time, fewer denied claims, faster approvals, improved revenue flow, lower staff burnout, and enhanced patient satisfaction through timely care and clearer communication.
Such software provides real-time visibility into authorization status, reduces errors and denials, streamlines billing processes, accelerates payments, and ultimately improves financial outcomes for healthcare providers.
Manual prior authorizations are time-consuming (16-40 minutes/request), error-prone, and costly (up to $11 per request). They increase denials, create payment delays, add staff stress, and reduce time available for patient care.
Automation saves staff time by handling repetitive tasks, data entry, and follow-ups, allowing healthcare workers to focus on higher-value tasks. It reduces burnout and improves employee satisfaction and productivity.
Analytics use historical data and AI to predict which claims may be denied before submission, allowing proactive correction. This reduces denials, saves time and money, and improves overall claims management.
Integration with Electronic Health Records (EHR) and practice management systems allows automatic data population, reduces errors, ensures compliance with payer rules, enables real-time updates, and supports seamless workflows enhancing overall efficiency.
Simbo is using AI agents to automate all phone related workflows. Connect now to know more.
Schedule AI Agents Demo Now© Since 2019, Simbo AI.
