How Automation Can Reduce Prior Authorization Workloads is an important question for healthcare organizations facing growing administrative demands, prior authorization helps health plans determine whether certain medical services, procedures, medications, and treatments meet coverage and medical-necessity requirements.

However, processing these requests may often require repetitive manual steps such as heavy clinical documentation, payer communication, and status tracking. By automating prior authorizations with technology, healthcare organizations can optimize a tedious, error-prone process to save time and resources, improve efficiency, and ultimately help to get providers back to focusing on what matters most: the patient. Prior authorization automation can help reduce time spent on non-core activities and support better patient care as well as ensure the accuracy and faster processing of claims to improve the patient’s experience.

Why Prior Authorization Creates an Administrative Burden

A typical prior authorization process may require staff to:

• Determine whether authorization is required
• Verify insurance and eligibility information
• Collect clinical documentation
• Review medical history
• Complete payer-specific forms
• Submit supporting documents
• Communicate with payers
• Track authorization status
• Respond to requests for additional information
• Record approval or denial decisions

When executed manually across multiple payers this can cause an exponential increase in workload

Different plans also require different authorizations, forms, portals, and documentation which fragments the process and results in prior authorizations that are tedious to request and administer. Automation helps streamline these tasks and unify the process into one logical workflow.

1. Automating Authorization Requirement Checks

One of the first steps in the process is determining whether a certain service requires prior authorization.

Instead of staff having to check each coverage policy or portal, an automated system would be able to use information like the patient’s plan, procedure, diagnosis, or requested service and determine based off of that whether or not it needs any sort of authorization.

This system would allow staff to spend their time only on those requests which required intervention, instead of doing work for all claims that just need to be submitted normally.

2. Automating Data Collection From the EHR

Much of the information needed for an authorization request already exists inside the electronic health record (EHR).

Automation can retrieve relevant patient and clinical information, including:

• Patient demographics
• Insurance details
• Diagnosis and procedure codes
• Clinical notes
• Medication history
• Laboratory and imaging results
• Previous treatments

EHR integration reduces repetitive data entry and can help improve the accuracy and completeness of authorization requests.

3. Streamlining Clinical Documentation

Clinical documentation is one of the critical elements of prior authorization. The personnel may spend much time searching for relevant information in medical records to establish medical necessity. Intelligent automation can help find the needed documents and organize them according to the requirements of the payers.

For instance, an automated workflow can recognize the relevant prior procedures, tests, or notes to the chart necessary to justify the requested medical service. It can save time on chart review and avoid claim rejections due to incomplete documentation.

4. Automating Prior Authorization Submission

Once the required information has been gathered, automation can assist in preparing and electronically submitting the request.

Electronic prior authorizations can help reduce faxes, calls, and repeated portal navigation.

Interoperability initiatives in modern healthcare are promoting the adoption of standardized electronic workflows. CMS is promoting the use of electronic prior authorizations via API (FHIR) to improve communication between providers and payers.

A connected submission process can streamline the exchange of complete information with the relevant health plan and create an auditable trail for each request.

5. Automating Authorization Status Tracking

Submitting a request is only one part of the prior authorization workflow.

Administrative teams may need to repeatedly check whether a request is:

• Received
• Pending
• Approved
• Denied
• Waiting for additional information

Automated status tracking can consolidate this information and indicate which requests require attention.

Instead of having to log in to numerous payer portals to check the status of various authorizations, staff can have a birds-eye view of all outstanding authorizations via a centralized dashboard, which could cut down on redundant follow-ups.

6. Using AI to Support Prior Authorization

Artificial intelligence can be utilized to improve the process of prior authorization by automating the repetition information-processing tasks with the help of big data, both structured and unstructured.

AI-powered tools can assist with:

• Clinical information extraction
• Medical record summarization
• Documentation matching
• Identifying missing information
• Prioritizing authorization requests
• Supporting medical-necessity documentation
• Routing requests to the appropriate staff

The goal is not to replace humans with machines but rather allow clinicians to focus on complex, interesting cases that require a human touch.

Benefits of Prior Authorization Automation

A well-designed automated prior authorization workflow can provide several benefits.

• Reduced Administrative Work: Automating repetitive processes such as data entry, gathering of information, submission, and verification of status can help ease the burden of administrative personnel.
• Faster Processing: Using electronic workflow can help providers in expediting the process of request preparation and submission resulting in fewer delays.
• Fewer Errors: Automated record transfers from interconnected healthcare systems to other facilities may minimize human errors related to manual data entry of patient and clinical information.
• Better Visibility: Consolidating requests provides clinicians with an overview of the status of their applications, processing time, approvals, and rejections.
• Improved Patient Experience: Procedure or medication-related delays due to authorization requests can result in treatment or procedure postponement. Enhanced processing of authorization requests can enable healthcare organizations to accelerate the approval process.

What to Look for in an Automation Solution

Healthcare organizations evaluating prior authorization automation should consider several factors.

• EHR integration: The platform should be able to connect with existing clinical systems.
• Payer connectivity: It should support communication with the organization’s major health plans.
• Workflow flexibility: Different specialties and payers may have different requirements, so workflows should be configurable.
• Human oversight: Automation should allow staff to review information and intervene when necessary.
• Security and compliance: Patient information must be handled using appropriate healthcare privacy and security practices.
• Analytics: Organizations should be able to measure authorization volume, turnaround time, pending requests, and other operational metrics.

The Future of Prior Authorization

Prior authorizations are shifting from a disparate, manual process to a more integrated digital workflow.

Electronic prior authorizations, interoperability, FHIR APIs, intelligent automation, and AI can all play a role in reducing administrative burden, as well as improving communication and collaboration between providers and payers.

It’s about getting the right information to the right payer at the right time and removing as much unnecessary manual intervention as possible.

Transform Prior Authorization Workflows With ClinDCast

Healthcare organization can digitize the prior authorization process with the help of ClinDCast’s healthcare technology and digital transformation solutions. With the help of healthcare automation, EHR integration, interoperability, data management, and intelligent workflow, ClinDCast enables the reduction of redundant administrative work and empowers effective clinical documentation, payer-provider communication, and authorization process.

By embracing the digitization of electronic prior authorization, healthcare organizations can benefit from end-to-end connected and automated solutions for the authorization of medical services, making the entire process more efficient and leaving more time for patient care.