Enhancing Patient Care Delivery through Automated Prior Authorization Processes in Healthcare Systems

The prior authorization process in most healthcare places today involves many manual steps like phone calls, faxing, and emails to insurance companies.
According to the 2024 CAQH Index Report, manual prior authorization transactions take about 24 minutes on average, while using payer portals takes 16 minutes.
These transactions cost healthcare providers about $3.41 each when done manually.
Such delays make patients wait longer for treatments, cause interruptions in care, and increase the chance that patients might stop their medication or treatment.

Doctors have a heavy amount of paperwork related to prior authorizations. On average, they handle 39 PA requests every week, which equals almost 13 hours spent on these tasks.
This can cause a lot of stress and burnout for doctors. Nearly half of the prescribers say PA processes affect their daily work and job happiness.
Providers get more upset when approvals are delayed or denied because it affects how well patients get treated.
For example, 89% of prescribers agree that delays in PA hurt patient health, and 19% say serious events have happened because of these delays.

Even though electronic health record (EHR) systems exist, only 26% of doctors say they have electronic prior authorization (ePA) features built in.
Many doctors still use phone calls (59%) and faxes (45%) to handle authorization requests, which causes more delays and inefficiencies.
This creates hold-ups, especially in busy clinics and hospitals.

Real-World Examples of Automated Prior Authorization Success

• Atlantic Health System in New Jersey used AI and machine learning with process changes to fix their radiology prior authorization workflow.
  Their system manages 1.3 million payer rules from over 300 health plans, automating paperwork and working with payer portals in real time.
  This cut processing times by more than half and now 82% of prior authorizations are done without manual work.
  They say it is important to improve processes before adding technology because automation alone can make things worse if workflows are bad.

• UNC Health used Surescripts’ Touchless Prior Authorization, an automated system connected to EHRs that sends PA requests using patient data directly from charts.
  The system takes about 27 seconds to process approvals, lowers appeal rates by 88%, reduces denials by 68%, and cuts abandoned requests by 41%.
  Doctors and staff feel less stressed and spend more time with patients.
  They also save hundreds of staff hours every year with automation.

• A rural hospital in Louisiana worked with Jorie AI to use robotic process automation (RPA) for prior authorizations.
  This led to a denial rate dropping to 0.21%, raised cash flow by $2.28 million, and improved payment collections by 15%.
  The system pulls data from EHRs, sends requests electronically, tracks authorizations, updates billing, and finds denial patterns to fix future submissions.

• A community health network in Fresno, California saw a 22% drop in prior authorization denials and 18% reduction in service-not-covered denials after using AI-based claim reviews before submissions.
  This saved a lot of time spent on appeals and helped their revenue cycle.

These examples show how automated PA processes help healthcare providers.
They reduce delays, let patients get treatments faster, and help healthcare facilities perform better economically.

Benefits of Automated Prior Authorization for Healthcare Organizations

• Time Savings and Efficiency
  Automation cuts down the average time per prior authorization by about 14 minutes compared to manual work.
  These tools work all day and night, handling requests without staff being there all the time.
  This frees up staff to do other important jobs or focus more on patients.
  Automated systems handle many payer rules well, lowering mistakes that cause denials.

• Cost Reduction
  Automated PA lowers the cost per request from $3.41 to five cents, cutting administrative costs by 98%.
  Healthcare systems that use automation can spend money better and stay more financially stable.
  Also, outsourcing parts of the process with automation can save up to 70% on staff costs.

• Improved Patient Care Delivery
  Faster PA approvals start treatments sooner, lowering health risks from delays.
  Automation reduces waiting times from days or weeks to hours or minutes.
  Practices find patients are happier because treatments and prescriptions come faster and workflows run more smoothly.

• Reduction in Denials and Appeals
  AI looks at past denials to find common problems and improves PA submissions.
  AI-driven systems have helped cut denials by 22% and appeals by 68% related to missing info.
  This makes revenue more steady and cuts down on extra work.

• Enhancement of Regulatory Compliance
  The Centers for Medicare & Medicaid Services (CMS) released a rule in January 2024 that requires using HL7 FHIR-based APIs for real-time PA data sharing.
  This helps track soon and supports following rules set for 2027.
  Automated systems help providers meet these rules and fit easily with EHRs and payer systems.

• Support for Staff Satisfaction
  Too much paperwork causes burnout in healthcare workers.
  Reducing time spent on PAs helps doctors and staff feel better about their jobs.
  Organizations like UNC Health saw more positive staff reactions after using automation.

AI and Workflow Automation in Prior Authorization: Transforming Healthcare Operations

Artificial intelligence (AI) and workflow automation are important for improving prior authorization.
AI uses machine learning and natural language processing (NLP) to read, extract, and match clinical data with what payers need automatically.
Robotic process automation (RPA) handles repeated tasks like sending forms, checking insurance, and updating cases.

Key roles of AI and automation include:

• Rule Management at Scale: AI manages millions of payer rules like diagnosis codes, CPT codes, and patient eligibility to make sure submissions follow rules before sending.

• Real-time Communication: Systems give instant updates on PA status, tell providers if data is missing, and create automatic appeals if needed.
  This reduces waiting and helps providers and payers work together better.

• Denial Mitigation: AI checks past denials to find common errors and changes future submissions to avoid repeats.
  This speeds approvals and improves money flow.

• Integration with EHR and Billing Systems: Solutions connect with health records to pull clinical info without retyping, which improves accuracy.
  Billing systems also get updated directly after approvals, which reduces breaks in revenue processes.

• Hybrid Automation with Human Oversight: AI automates routine and some complex tasks, but people are still needed for tricky cases like appeals or exceptions.
  Many places use a mix of automation for simple cases and humans for difficult ones.

About 46% of U.S. hospitals now use AI in managing money processes like prior authorizations.
This helps call centers work 15%-30% better, cuts manual errors, and quickens financial work.

Future Directions and Best Practices

To improve prior authorization automation, healthcare leaders should:

• Look closely at current processes to find inefficiencies before using automation, like Atlantic Health System did.
• Pick platforms that can handle big data and many payer rules, and that work well for different business needs.
• Make sure these platforms connect well with current EHRs and billing systems so workflows stay smooth.
• Train staff to help them use the new tools well and keep people involved where needed.
• Watch for rule changes like CMS’s HL7 FHIR API requirements to stay updated.
• Think about mixed models that combine automation with outsourced experts to save costs and keep accuracy while handling busy times.

Automation and AI will keep growing in prior authorization and money management in healthcare.
In the next years, new tech like generative AI is expected to do more difficult tasks and reduce delays, denials, and costs even more.

Summary

Automated prior authorization offers clear benefits to healthcare organizations in the United States.
These tools reduce paperwork, increase provider productivity, improve patient access to care, and boost financial results.
Healthcare managers, owners, and IT leaders who focus on these digital tools will be better able to handle growing paperwork and support better outcomes for patients and staff.