Prior authorizations (PAs) are a necessary but often burdensome part of healthcare. Prior authorizations ensure that care is medically necessary and cost-effective by requiring approval to administer specific treatments or medications.
Recent mandates from the Centers for Medicare & Medicaid Services (CMS) aim to streamline this process by pushing for greater use of automation and electronic prior authorization solutions.
However, despite these efforts, many providers face significant delays and administrative burdens, impacting patient care and daily operations.
In this blog post, we’ll explore the challenges associated with prior authorizations and how innovative technology solutions, like Vim’s, can streamline the process, improve patient care, and enhance provider efficiency.
What Is the Purpose of Prior Authorization?
A prior authorization is a request from a healthcare provider to a payer, such as an insurance company, for approval to provide a specific medical service or medication.
Insurers require this prior approval to confirm that the recommended treatment, medication, or procedure meets the coverage criteria of the patient’s health plan.
While this safeguard protects the healthcare system’s integrity, it often introduces delays, especially for patients who require urgent or specialized treatments.
The Current Process for Prior Authorizations and Why It’s Challenging
Today’s prior authorization process is largely manual and varies between payers, leading to inconsistent workflows and frequent administrative hurdles. Providers must fill out forms, submit documentation, and wait for responses from insurers—which can take days or weeks.
This creates significant delays in treatment, complicates patient care, and adds to the workload for healthcare staff. For providers already strained by day-to-day operations, the inefficiency and unpredictability of this system disrupt patient care and extend wait times.
The Growing Burden of Prior Authorizations
Several factors contribute to the increasing complexity of the prior authorization process. A key driver is the growing number of treatments and medications that require prior approval as payers seek to control healthcare costs.
Additionally, different insurance companies have unique requirements, which force providers to navigate a maze of varying criteria. This adds time and increases the risk of errors or missed approvals.
As a result of these negative implications around the prior authorization process, the American Medical Association and other medical organizations have been advocating for PA reform to streamline the process.
Alternative approaches being considered include:
- Gold card programs (exempting providers with high PA approval rates)
- Electronic PA systems
- Standardized PA forms
- Shorter response time requirements
The Impact of the Prior Authorization Process
The statistics around prior authorizations highlight the significant challenges providers face. According to an American Medical Association (AMA) survey, 95% of physicians reported delays in patient care due to prior authorizations, and 24% of doctors said the process has led to a serious adverse event, such as hospitalization.
According to a 2022 survey by the Medical Group Management Association (MGMA), 89% of medical practices said that prior authorization requirements had increased over the past year.
Treatment delays are a significant concern, with 82% of physicians indicating that prior authorizations can lead to care disruptions, resulting in potential negative health outcomes.
Furthermore, a Kaiser Family Foundation study revealed that about 16% of insured adults’ prior authorization requests were denied or delayed by their health insurance carrier, adding another layer of complexity and frustration for providers and patients alike.
How Providers Can Avoid Prior Authorization Denials
Avoiding prior authorization denials involves meticulous attention to insurer requirements and detailed documentation. Streamlining this process is essential for maintaining operational efficiency and ensuring timely patient care.
Some strategies providers can use to avoid denials include:
Understand payer-specific requirements
Each insurance company has guidelines for prior authorizations, including required documentation, timelines, and specific criteria for approval. Providers can reduce the risk of denials by staying informed about each payer’s unique requirements.
Track data for insights
By tracking prior authorization requests and outcomes over time, providers can predict future outcomes, identify patterns in denials, and take proactive measures.
Pre-certify frequently used services
Providers can avoid denials by pre-certifying services or medications commonly subject to prior authorization. Establishing protocols to ensure automatic pre-certification for certain procedures can streamline the process.
Use prior authorization solutions
Technology solutions can automate much of the manual work involved in submitting prior authorization requests. Vim’s Prior Authorization solution provides an end-to-end workflow that connects typically disjointed processes into a single view within the EHR. More on this below.
How CMS Is Addressing Prior Authorization Challenges
The Centers for Medicare & Medicaid Services (CMS) has acknowledged the difficulties associated with prior authorizations and is taking steps to improve the process.
Recent proposals include greater automation and standardized data exchange through adopting electronic prior authorization solutions.
CMS is also pushing for faster turnaround times for decision-making and better communication between providers and payers.
These initiatives aim to reduce the administrative burden on providers while ensuring patients receive timely and appropriate care.
Technology Solutions for Prior Authorizations
Several technology solutions are emerging to help streamline the prior authorization process. Automated systems like electronic prior authorization (ePA) tools enable providers to submit requests directly from their electronic health records (EHRs), reducing the time and effort required to gather and submit documentation.
Additionally, artificial intelligence (AI) and machine learning technologies are being used to predict approval outcomes and flag potential issues before requests are submitted. These tools help reduce delays and improve accuracy, ultimately speeding up the approval process and improving patient outcomes.
How Vim’s Solution Addresses Prior Authorization Challenges
Vim offers a comprehensive prior authorization solution designed to address the specific challenges of the prior authorization process:
- Enable a single point of access to patient-specific health plan data, and prior authorization requirements (from payer and third-party sources) delivered when needed – at the point of care.
- Modernize EHR workflows with a context-aware connection that uses active clinical orders to trigger and auto-populate prior authorization checks when available.
- Simplify the entire authorization process with in-app code lookup, approval requirements, case submission, and status search and update (if available from payer and third-party sources).
- Unify management of prior authorization status checks with searchable reference numbers (if available from the payer and third-party sources).
Additionally, Vim’s Developer Platform, Vim Canvas™, allows for novel prior authorization data and applications to be delivered at the point of care using Vim’s in-EHR integration layer.
Healthcare innovators solving prior authorization challenges in new ways can build their solutions once on Vim Canvas™ and deploy them across all Vim-supported EHRs.
This allows providers to access prior authorization solutions from a consistent interface and helps innovators get to market faster.
Final Thoughts
Prior authorizations are a necessary part of the healthcare system but often present significant challenges for providers and patients. By adopting advanced technology solutions like Vim’s, healthcare organizations can alleviate the administrative burden on providers, improve collaboration between providers and payers, and ultimately provide better patient care.
FAQs
Is prior authorization good or bad?
It’s neither inherently good nor bad but serves as a necessary check to ensure care is medically necessary and cost-effective. However, it can introduce delays and administrative challenges when handled inefficiently.
How long does it take for prior authorization?
The timeline varies by insurer and procedure but typically ranges from a few days to several weeks.
Can a prior authorization be denied?
Yes, a request can be denied if it doesn’t meet the insurer’s medical necessity or documentation criteria.
What happens if prior authorization is not obtained?
The insurance provider may refuse to cover the service if prior authorization isn’t obtained, leaving patients responsible for the total cost.
