How Automating Prior Authorization Can Revolutionize Patient Care Delivery and Reduce Administrative Burdens

Prior authorization is needed to make sure a treatment or procedure is right and covered by the patient’s insurance. But this process often uses old methods like phone calls, faxes, and emails. These ways create many problems:

• Time-Consuming Tasks: The 2024 CAQH Index Report shows that providers spend about 24 minutes for each prior authorization request when using phone, fax, or email. If they use health plan portals, it still takes around 16 minutes per request. When a practice has many requests every week, this adds a lot of extra work and delays care.
• Administrative Burden and Burnout: The American Medical Association (AMA) found that doctors spend about 13 hours a week managing prior authorizations, handling around 39 requests. This heavy workload causes 89% of doctors to feel burned out. Also, 40% of doctors hire more staff just to handle these tasks.
• Delays Resulting in Patient Harm: Over 90% of doctors said that delays in prior authorization hurt patient outcomes. About 29% reported serious problems like hospital stays or death because of these delays. Plus, 82% saw patients stop treatment due to difficulties with authorizations.
• Increased Costs and Inefficiency: Manual prior authorizations cost roughly $3.41 each, while automation can cut this to $0.05 per request. This more than 98% cost drop can make healthcare much more efficient and less expensive.
• AI Use Causing Concerns: Although AI can help automate prior authorizations, the AMA noted worries about AI misuse. About 61% of doctors fear that AI systems used by insurers might deny more requests without proper human checks. Sometimes these denials are 16 times higher than normal, which can stop needed care.

With these issues in mind, the current way of doing prior authorizations is not working well. Changes are needed to keep the purpose of prior authorization but make it faster and more accurate for patients and providers.

Automating Prior Authorization: A Shift Towards Efficiency and Patient-Centered Care

Faster, More Accurate Approvals

Using AI and workflow technologies to automate prior authorizations can fix many of the problems mentioned above. AI can quickly read and understand complex insurance rules and patient medical details. For example, GuideWell’s AI system approved 78% of prior authorization requests in under 90 seconds. This is much faster than before, which could take days or weeks.

Tools like machine learning and natural language processing can automatically find and check important medical documents. This reduces mistakes often made when entering data by hand.

With fewer errors and quicker responses, AI helps patients get the treatments they need faster. Clinics do not have to wait long for insurance answers, which speeds up care and makes patients happier.

Significant Reduction of Administrative Workload

Automation helps healthcare staff spend less time sending, tracking, and following up on prior authorizations. A health network in Fresno, California, found that using automation cut prior authorization denials by 22% and other coverage denials by 18%. This saved 30 to 35 staff hours every week without needing to hire more people.

Automated updates and alerts also reduce the need for phone calls and manual checks. Providers can see the status of requests in real time, making their work easier.

Improved Financial Sustainability for Practices

Automation not only saves time but also helps practices avoid claim denials related to prior authorizations. Automated checks can find problems with eligibility or missing information before claims are sent. This lowers the chance of costly denials.

A hospital in New York called Auburn Community Hospital reported a 50% drop in cases where discharged patients were not billed on time. They also saw coder productivity improve by more than 40% after using AI in their revenue cycle. This leads to better cash flow and use of resources.

Compliance with Regulatory Requirements

The Centers for Medicare & Medicaid Services (CMS) has rules that require health plans to use HL7 FHIR-based APIs to share prior authorization data in real time by 2027. Automation fits these rules by providing easy-to-use workflows that can handle lots of data and different business needs.

For example, HealthEdge’s Prior Authorization Catalog automatically processes requests and supports “Gold Card” programs, where trusted providers get faster approvals based on certain payer rules.

AI and Workflow Automation in Prior Authorization and Beyond

Integrating Intelligent Automation within Healthcare Practices

AI systems can connect prior authorization tasks directly to electronic health records (EHR). They can fill out forms and submit requests automatically during patient visits. This cuts down on re-entering data and reduces mistakes.

This integration helps staff work better and lets providers focus more on caring for patients. Automating repetitive tasks like prior authorization and claims submissions could save billions each year. The U.S. spends about $353 billion yearly on administrative costs, and prior authorization is a big part of that. AI automation could save more than $168 billion.

Enhancing Transparency and Communication

AI also helps communication between providers, insurance companies, and patients by giving real-time updates and alerts. This makes the process clearer and reduces worry for everyone. Patients feel less anxious when they get timely news about their treatment approvals.

Supporting Workforce Management

Automation helps manage the workforce by saving staff time and lowering burnout. Providers can use their team better, boosting job happiness and cutting costs from turnover. Advanced AI tools can also help plan workloads and staffing needs.

Addressing Risks and Ethical Considerations

Even though automation has many benefits, using AI too much can cause problems. The AMA says AI should support human decisions, not replace them. There must be proper checks to make sure AI doesn’t cause harm by denying care wrongly or making unfair choices.

Healthcare leaders should use AI transparently and follow rules. Doctors need to stay involved so AI tools match real medical needs and are trustworthy.

Impact on Healthcare Providers and Patient Outcomes

• Reduced Denial Rates: The Fresno health network reported a 22% drop in prior authorization denials by using AI and front-end checks.
• Increased Productivity: Auburn Community Hospital raised coder productivity by more than 40% and cut pending billing cases by 50%, helping finances and operations.
• Lower Costs: Automation reduces prior authorization costs from $3.41 to $0.05 per request, making it cheaper for providers.
• Faster Care Delivery: Automated approvals in real time stop treatment delays, which is important for serious or long-term health problems.
• Improved Patient and Provider Satisfaction: AI tools improve communication and reduce follow-up work, making care easier for patients and staff.

Considerations for U.S. Medical Practice Administrators, Owners, and IT Managers

• Choosing AI Systems that Integrate Seamlessly: Automation works best when built into existing workflows and EHR systems. This reduces problems and helps staff learn faster.
• Balancing Automation with Human Oversight: Systems should help providers without taking away their medical judgment. Ethical rules must be followed.
• Planning for Regulatory Compliance: CMS rules are coming soon. Practices should invest in FHIR-based automation now to be ready and avoid penalties.
• Evaluating ROI Based on Reduced Denials and Time Savings: Understanding how automation lowers denials and saves time helps make the case for initial costs.
• Preparing Staff for Change Management: Training and involving staff early makes switching to automation easier and more effective.
• Focusing on Patient Experience: Automation that improves communication and transparency helps patients and leads to better care.

By thinking about these points, medical administrators and IT managers can make their practices better at handling prior authorizations. This reduces work for staff and leads to faster, better care for patients. Automating prior authorization is a useful step toward updating how healthcare works and improving the experience for everyone involved.