Reducing the Prior Authorization Burden with Practical Workarounds, Best Practices and Technological Strategies
Prior authorization is quietly becoming one of the biggest operational stress points in U.S. healthcare. According to the 2024 American Medical Association (AMA) Prior Authorization Physician Survey, more than 90% of physicians have reported that delays in getting the prior authorization have disrupted their patient care, with nearly one in three physicians stating that is has also led to serious adverse events in patients. On an average, physicians must complete close to 40 prior authorization requests per week, that involves spending hours in navigating the payer portals, documentation requests, and follow-ups. (Source: 2024 American Medical Association Prior Authorization Physician Survey) What once was intended as a utilization safeguard has now evolved into a major barrier not only for patient access, but also for the revenue flow. For healthcare organizations and medical practices, reducing this prior authorization burden has become both a financial and operational imperative demanding smarter workflow, better strategies for documentation, and the use of the right technology. This blog guides you through the practical workarounds and modern RCM approaches, that is being implemented by Shoreline Healthcare Technologies, creating a measurable difference.
What is Prior Authorization and Why does it Matter?
Prior authorization is a utilization management tool used by insurers and payers to determine if certain medications, procedures, or services will be covered under a patient’s plan before they are delivered.
PA serves several purposes:
- ✔ Ensures medically appropriate and evidence-based care
- ✔ Prevents unnecessary expensive treatments
- ✔ Helps manage risk and reduce wasteful spending
What happens when providers miss getting a PA?
Missing a prior authorization before rendering the service might result in claim getting delayed or even denied with patients experiencing higher out-of-pocket surprises.
- ✔ Patients sometimes must pay the full price when a PA is denied or not obtained that increases their out-of-pocket costs.
- ✔ Claims that are denied or re-appealed can increase the AR days and revenue risks with write-offs.
- ✔ Clinicians and billing teams have to spend hours per week on the rejected claims increasing their administrative burden.
What Makes Prior Authorization So Complex for Providers?
Getting a prior authorization involves complex documentation that should follow payer-specific criteria with repeated follow-ups which would disrupt the clinical workflows. Studies show that clinicians and practice staff spend hours each week handling PA tasks. This excess administrative burden contributes to:
- ✔ Provider burnout
- ✔ Slow turnaround times for clinical decisions
- ✔ Delays in care delivery
- ✔ Increased operational costs
Adding to this healthcare providers consistently identify
- ✔ Lack of transparency around criteria and required documentation
- ✔ Manual processes and phone-based follow-ups
- ✔ Inconsistent payer rules and exceptions
- ✔ Repeated denials even when criteria appear to be met
- ✔ Difficulty in tracking authorization status in real time
These challenges vary widely across specialties, payer types and care settings significantly increasing the administrative overhead and slowing down the prior authorization workflow efficiency across healthcare organizations.
How does Prior authorization impact patients?
Patients often have to bear the indirect consequences of PA delays which can postpone treatment, interrupt medication therapy and increase patient financial responsibility, directly impacting care continuity and satisfaction.
High-impact, Strategic Workarounds
Standardizing the Documentation Processes
The key challenge in PA is the inconsistency in documentation. By standardizing the templates providers can collect and submit all the necessary clinical information that would reduce the denials.
Standardize the documentation templates by including
- ✔ Relevant diagnosis codes
- ✔ Prior treatment history
- ✔ Evidence of medical necessity
- ✔ Supporting lab or imaging results
- ✔ Creating checklist for high-volume service MRI, imaging, specialty drugs etc.
Standardized Prior Authorization Checklists
Based on our real-world prior authorization and revenue cycle management engagements, Shoreline Healthcare Technologies have developed service-specific documentation checklists that include:
- ✔ Required CPT/HCPCS codes
- ✔ Diagnosis code alignment
- ✔ Supporting lab or imaging reports
- ✔ Clinical notes summarizing medical necessity
- ✔ Step therapy documentation (if applicable)
We have observed that these steps would significantly help in reducing the reworks and resubmission cycles.
Utilize the Electronic Prior Authorization (ePA) Systems
Electronic prior authorization systems automate much of the PA workflow, enabling:
- ✔ Automated rule checks against payer criteria
- ✔ Digital submission of required documentation
- ✔ Faster approval times
These ePA systems can integrate directly into the Electronic Health Records (EHRs) so that they can easily pull the clinical data reducing the errors due to manual entry and delay.
Delegating Authorization to Specialized Teams
Organizations can assign PA tasks to dedicated teams such as care coordinators or utilization review specialists for complex PAs who are experienced in managing the payer requirements. They
- ✔ Use templates for appeals and clinical justifications
- ✔ Handle time-sensitive submissions and escalations
- ✔ Track turnarounds and feed data back into the checklist
This model improves speed and consistency while allowing clinicians to focus on direct care.
Gold-card programs and targeted credentialing
Check with the high-volume payers if they offer “gold card” or high-performing provider exemptions. So, by tracking the approval rates and submitting the performance data providers can earn exemptions. If the approval rate is consistently high, some payers might consider reducing the PA requirements for specific services or providers.
Education and Continuous Training
Provide necessary trainings to the staff to stay current on:
- ✔ Evolving payer criteria
- ✔ Use of automation tools
- ✔ Appeal strategies for denials
With regular education we can reduce unnecessary late submissions and improve first-pass approval rates.
AI-Driven Platforms for Smarter Prior Authorization
Recent advancement in artificial intelligence (AI) tools is beginning to reshape how prior authorization is handled in real-time. Optum, of UnitedHealth Group has recently announced the launch of two AI-powered digital prior authorization solutions designed to modernize and simplify the authorization lifecycle.
- ✔ Digital Auth Complete
- ✔ InterQual Auth Accelerator
Digital Auth Complete It focuses on the provider side of the workflow by embedding prior authorization intelligence directly into electronic health record (EHR) systems. It automatically identifies when an authorization is required, assembles relevant clinical documentation, and submit requests to across over 250 payer systems. It is reported to eliminate 45% of manual touches, boost the efficiency of document-processing by 80%, and achieve a 96% of first-pass approval rate.
InterQual Auth Accelerator It supports payer clinical review teams. This AI-enabled tool analyses the incoming authorization requests against the payer guidelines and policies, highlighting the key clinical indicators for reviewers. It is designed to assist human for decision-making, helping them to reduce their review time at the same while maintain clinical oversight and compliance standards.
These tools demonstrate the efficiency of technology in reducing the prior authorization burden across the entire ecosystem. It minimizes the redundant data entry process and improves the accuracy of documentation.
We at Shoreline Healthcare Technologies have adopted similar AI-driven platforms, helping healthcare providers to transform the manual bottleneck of prior authorization into a streamlined, data-driven process that supports patient-centered care in timely manner.
Best Practices to Optimize Prior Authorization
Partnering With Payers for Transparency
Establishing an open communication with the payers and having regular feedback loops can:
- ✔ Clarify criteria and expectations
- ✔ Reduce repeated submission errors
- ✔ Predict upcoming changes to authorization rules
This partnership fosters mutual trust and efficiency and increase the turnarounds for PA.
Leveraging Interoperability and FHIR Integration
Aligning the systems to the modern interoperability standards can reduce the friction in the PA workflow. Fast Healthcare Interoperability Resources (FHIR) standards allow real-time data exchange among EHRs, payer systems, and authorization platforms that benefits for:
- ✔ Faster eligibility checks
- ✔ Reduced data entry work
- ✔ Automated verification of clinical information
Implementing Pre-Authorization Rules Engines
Implement rules engines that enables predictive decision support and codifies payer criteria to assess authorization requirements and flag potential eligibility issues before submission. This proactive approach helps to prevent the submissions that might fail and the time wasted on incomplete requests.
The Centers for Medicare & Medicaid Services is mandating the implementation of interoperability and adoption of API-enabled systems to increase transparency and accelerate the process of getting PA. Healthcare organizations should bring changes to their prior authorization workflows by integrating ePA, strengthening documentation protocols, and leveraging intelligent RCM automation that would reduce the denials, improve turnaround time, and protect the stability of their revenue. Shoreline Healthcare Technologies partners with healthcare organizations to redesign prior authorization workflows, implement automation frameworks and optimize payer rule management that helps to transform prior authorization workflows from an operational bottleneck into a predictable, data-driven process.
FAQs
Q1. Why Is Prior Authorization Required?
+Payers use prior authorization for:
✔ Cost Containment: For preventing the overutilization of high-cost procedures and drugs.
✔ Clinical Review: To make sure that treatments meet evidence-based guidelines.
✔ Fraud Prevention: To monitor inappropriate or unnecessary services.
Q2. What are the factors that have led to the administrative complexity in obtaining a PA?
+The administrative complexity for obtaining a PA has increased due to:
✔ Multiple payer portals
✔ Inconsistent criteria
✔ Manual documentation submission
✔ Lack of interoperability
✔ High rework and appeal cycles
Q3. What do you mean by Gold-Card program?
+A Gold-Card program is an initiative offered by some health plans to high-performing providers for exempting the process of prior authorization Providers who have consistently demonstrated the evidence-based care, high approval rates, and low denial or appeal volumes are “gold-carded,” so that they can bypass prior authorization process for certain services. This program would reduce the administrative burden, speed the access to care and rewards providers for delivering the appropriate, high-quality treatment.
Q4. What are the key metrics that an organization can track to improve their PA workflows?
+
Metrics like
✔ Average turnaround time
✔ First-pass approval rate
✔ Denials by reason
✔ Time spent per authorization
can be tracked to improve the prior authorization workflows.
Q5. How can Providers Reduce the Prior Authorization Delays?
+Providers can reduce the delays caused in getting prior authorization by implementing a standardized documentation templates that aligns with diagnosis and procedure codes and payer specific criteria, use of electronic prior authorization (ePA) systems and continuously monitoring the authorization turnaround metrics.
Sharanya Rajmohan
Content Writer
Sharanya brings clarity to the complexities of medical billing and healthcare regulations. With a knack for turning industry shifts into straightforward, actionable insights, her blogs help readers stay informed without the jargon.
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