Why Is It So Hard To Streamline Prior Authorizations?

For many providers, obtaining a prior authorization (PA) involves manually faxing documents to a payer or sitting on hold for a long time – an inefficient and error prone process. The solution is not as easy as adopting automation. As we learned in a recent panel of experts from J2 Global, WEDI and CAQH, addressing the challenge requires technology as well as knowledge to get the PA request correct the first time it is submitted – thus avoiding delays and extra manual effort.

Prior authorization (PA) is a check run by insurance companies and third-party payers before they agree to cover the cost of certain prescribed medications and medical procedures. For many healthcare providers obtaining a PA is challenging process.

For example, it is not easy for a provider to know when a prior authorization is needed. Each payer has their own rules and within each payer there are multiple plans with their own guidelines. Deciphering those rules and guidelines often involves manually searching through paper documents or insurance company websites.

Once providers know that a PA is needed, now they must set about gathering the right clinical and administrative information in order to make a PA request. This often involves printing information from different internal systems and faxing those documents over to the payer.

When the PA submission is incorrect or incomplete, the payer will ask the provider for additional information. This back and forth can happen several times before the PA is complete.

This whole process is prone to error and delays which has a detrimental impact on patient outcomes. So why haven’t more providers and payers solved the PA challenge? According to the expert panel assembled by J2 Global and eFax, the answer is because providers and payers have not voiced their displeasure loud enough.

Thankfully solutions exist and there are things providers can do to ease the burden of PAs right now.

To find out what those are, check out this panel discussion featuring:

  • Jeffrey Sullivan, CTO, J2 Cloud Services
  • Jay Eisenstock, Board Chair, WEDI
  • April Todd, Senior Vice President, CORE and Explorations of CAQH

About the author

Colin Hung

Colin Hung

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

2 Comments

  • Great insight. There is an another huge challenge with the prior authorization – positive patient identification. Imagine getting an authorization for a wrong person connected to a wrong patient record! This happens over 8% of the time. That’s why many providers are adopting RightPatient for patient identity.

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