Can Technology Fix the Prior Authorization Challenge for Payers?

Healthcare Payers
3 minute read

Bottom line upfront:
Health plans developed prior authorizations (PA)s with noble goals in mind. And research shows PAs have achieved one of these goals: lowering drug costs. But the process has gotten out of control and become a growing burden for providers, payers, and members. The good news is, the right tech can solve prior authorization challenges.

Yes, prior authorizations add value

With all of the negative talk in healthcare circles about prior authorizations, it’s worth reminding ourselves why health plans created the process in the first place. As the advocacy group AHIP explains:

…Prior authorization can reduce inappropriate care by catching unsafe or low-value care and targeting where care may not be consistent with the latest clinical evidence—both of which can contribute to unnecessary costs and potential harm to patients.

Since health plans have such a wealth of aggregate medical data—far more than any single provider organization could access and analyze—payers are in a better position to uncover and apply insights to help members receive the best possible care. That includes, for example, Protecting members from ineffective treatments, preventing members from undergoing potentially harmful treatments, and reducing overall healthcare costs.

But prior authorizations have grown out of control

We all know the frustrations of prior authorizations that need to happen from our health plans before we can have a treatment for anything from an MRI for an orthopedic issue or to receive approval for a new drug. As patients, we know the delay can cause us more harm and we continuously call our provider office for updates. I know I have bugged my physician for authorizations and it’s frustrating for the administrative staff as well. AMA’s most recent physician survey found that doctors and their staff spend an average of 13 hours per week completing prior authorizations. And 84% of those doctors say that nearly 20% of drugs now require a prior authorization. Have you ever gone to the pharmacy to pick up your med only to be told your health plan didn’t approve it since you were supposed to try another drug first?

Now the picture is becoming clearer. As prior authorizations have expanded to cover more of a typical provider’s patient care, completing the paperwork-intensive process is consuming more of that practice’s time, focus, and financial resources. In fact, 40% of practices have employees working exclusively on prior authorizations, according to that AMA study.

How new technology and better interoperability can help patients get the treatment they need, faster

To the extent that payers can easily exchange patient data with providers—and automate how that data gets pulled into their system and directed to the right people for review—the staff will be able to process and respond to PAs more quickly, reduce errors in processing those requests, and get members the treatment they need more quickly and cost-effectively to improve care outcomes.

Consensus Cloud Solutions provides one set of solutions that enables interoperability across providers’ systems. Consensus’ integrated solutions leverage NLP and artificial intelligence to help payer organizations streamline their approval workflows; understand how to prioritize the most urgent authorizations and reduce human intervention, which can also be prone to error.

Our new prior authorization white paper is a must read to understand how innovative new digital solutions can turn the unwieldy authorization process around. Patients deserve to get fast treatment leading to better health outcomes and our providers should be treating patients and not dedicating staff’s time and resources to this costly administrative burden.