Technology Solutions to Streamline Prior Authorization Processes and Improve Patient Access to Care

Prior authorization is meant to help insurance companies control costs. It makes healthcare providers get approval before giving certain treatments, procedures, or medicines. While prior authorization tries to make sure resources are used correctly, the process can cause many problems.

A 2021 survey by the American Medical Association (AMA) found that 93% of doctors saw delays in patient care because of prior authorization. About 82% said these delays made patients stop their treatments. Providers spend around 13 hours each week just doing prior authorizations. Radiation oncology clinics face very high costs from prior authorizations, estimated at about $40 million every year. These costs include direct and indirect work from all the extra paperwork.

Delays and extra work also add to provider burnout and unhappiness. Nearly 90% of doctors said prior authorization made burnout worse. Patients often face long waits and uncertainty, which can harm their health or interrupt ongoing care.

Regulatory Efforts to Improve Prior Authorization

The government is trying to reduce prior authorization problems. The Centers for Medicare & Medicaid Services (CMS) made a rule called the CMS Interoperability and Prior Authorization Final Rule. It starts mainly in 2026. This rule applies to Medicare Advantage, Medicaid, CHIP, and some health plans through federal exchanges.

Key parts of the rule are:

• Response Time Mandates: Insurance companies must reply to urgent prior authorization requests within 72 hours and regular ones within seven days. This cuts wait times in some cases by half.
• Transparency in Denials: Insurance companies have to explain why they denied a request. This helps providers send appeals or try again.
• Public Reporting: Annual reports on prior authorization approval and denial rates must be shared publicly. This helps keep companies accountable.
• API Requirements: Insurance companies must use certain technical standards (called HL7 FHIR) so electronic prior authorizations can work better. This allows better data sharing between providers, payers, and patients.
• Patient and Provider Access APIs: These allow sharing of claims, clinical info, and prior authorization data to help coordinate care.
• Payer-to-Payer Data Exchange: This lets insurance companies share patient data when patients change plans, helping care continue smoothly.

The rule also adds an “Electronic Prior Authorization” measure to a payment system called MIPS. It encourages hospitals and doctors to use electronic tools for submitting prior authorizations.

Collaborative Industry Initiatives

Besides government rules, many healthcare groups and insurers work together to fix prior authorization problems. Groups like the American Hospital Association (AHA), American Medical Association (AMA), and others issued a statement to reduce the burden of prior authorization.

They plan to:

• Cut down prior authorization needs for providers who perform well.
• Remove unneeded prior authorizations for some treatments.
• Make rules for prior authorization clearer.
• Make sure care continues smoothly if insurance or prior authorization rules change.
• Speed up the use of electronic prior authorization at point of care.

This teamwork works to lower paperwork but still keep quality and safety checks.

Digital Solutions and Electronic Prior Authorization (ePA)

Moving from paper and fax prior authorizations to digital methods improves speed and efficiency. Electronic prior authorization connects with existing Electronic Health Records (EHRs). This lets providers send prior authorization requests inside the systems they use daily.

Surescripts’ ePA platform is one example. It helps reduce provider work and speeds up getting medicines. In 2022, electronic prior authorization use grew by 44%. Providers usually get answers in less than four minutes. The system uses specific questions for each plan that cut out extra paperwork, saving about 10 minutes for each request. One health system noticed a 6% increase in patients picking up prescriptions after using ePA.

Providers have shared their views. Candace Minter from Sentara Medical Group said her team now does ten electronic prior authorizations in the time it used to take for one or two on paper. Jennifer Kohlbeck from Advocate Aurora Health said she saves up to 45 minutes per medication authorization.

This digital method also shortens waiting for patients—saving more than two days—and improves talking between providers and insurance companies. Faster processing means patients can start needed treatments more quickly, which might lead to better health.

Automation Powered by AI and Workflow Integration

New tools using artificial intelligence (AI) change how prior authorization workflows work in healthcare. AI can read insurance rules, guess which requests will be approved, and fill out paperwork by using clinical data from EHRs.

For example, Surescripts’ “Touchless Prior Authorization” uses a system across the country to automatically add clinical info into prior authorization requests. Pilot tests showed:

• Up to 97% cut in average approval times.
• 25% of requests get automatic approval.
• Prescription abandonment dropped from 31% to 25%.
• Appeals dropped by 88%.
• Denials due to missing info fell by 68%.

These results mean much less work for medical practices and quicker treatment for patients. AI tools take away manual data work and repetitive tasks, letting staff spend more time with patients instead of on paperwork.

Hiring staff specialized in prior authorization and trained on these tools can also help. These specialists guide providers through complex insurance rules, lower denials, and improve talking with patients. This helps reduce staff burnout and raises satisfaction.

Evolving Standards and Integration Landscape

Technology supporting prior authorization relies on growing healthcare IT standards such as:

• HL7 FHIR APIs: Required by CMS, these allow electronic sending and receiving of prior authorization requests, including approvals, denials, and documents.
• Da Vinci Project Implementation Guides: These guides help companies exchange data in a way that works with many systems. Companies like 1upHealth follow these guides.
• NCPDP Electronic Prior Authorization Standards: These make it easier to connect EHRs, insurers, pharmacies, and review vendors.

Companies such as 1upHealth build their prior authorization solutions using FHIR standards. This ensures smooth connections with big EHR systems like Epic and Meditech. Their platforms show providers and payers real-time status of prior authorization.

Using universal data sharing lowers repeat data entry caused by many different portals and communication systems. It also helps apply programs where providers with good records may skip some prior authorization steps, cutting extra work.

Impact on Medical Practice Operations in the United States

For medical practice leaders and IT managers in the U.S., using these technologies and workflows is important for:

• Reducing Administrative Burden: Smoother prior authorization processes save staff time by cutting paperwork and phone calls.
• Accelerating Patient Access: Faster prior authorization decisions reduce treatment delays, helping patient health and satisfaction.
• Improving Revenue Cycle: Fewer denials and quicker approvals help practices keep good cash flow.
• Enhancing Compliance: Following CMS rules and joining electronic prior authorization programs helps avoid penalties and earn rewards.
• Optimizing Staff Well-Being: Less burnout from lengthy prior authorization work lets staff focus more on caring for patients.

Healthcare practices that use automated and AI-based prior authorization tools can better meet rising rules while running efficiently and improving patient care.

This changing environment shows growing agreement among policymakers, providers, insurers, and technology makers that modern prior authorization with digital tools and partnerships is needed for a healthcare system that lasts. Even though problems remain, AI-driven automation and better data sharing standards offer a helpful way forward for U.S. medical practices trying to give fast and good care to their patients.