Prior Authorization Solutions Reduce Administrative Burden

Prior authorization solutions can greatly reduce administrative burden. According to a study, healthcare providers spend an average of 20 hours per week on prior authorization tasks.

This is a significant amount of time that could be spent on patient care. In fact, 90% of healthcare providers report that prior authorization is a significant administrative burden.

Automating prior authorization processes can help alleviate this burden. By streamlining the process, healthcare providers can focus on what matters most - patient care.

Automating administrative processes could greatly benefit prior authorization workflows. Only 21% of prior authorizations are fully electronic, according to the Council for Affordable Quality Healthcare's 2021 CAQH Index.

Digitizing the process would greatly diminish providers' administrative burden. The medical industry could save $437 million a year if seamless electronic communications were within reach.

A reduction in administrative costs is one of the key benefits of automating prior authorizations. This would be a significant impact, considering the current state of affairs.

Automating administrative processes could also lead to faster access to patient care due to accelerated decision timelines. This would be a huge relief for patients who often have to wait for what feels like an eternity to get the care they need.

Here are some of the specific benefits of automating prior authorizations:

Navigating the prior authorization process can be a significant challenge for healthcare providers and patients alike.

Gathering documentation, submitting requests, and following up can be time-consuming, significantly impacting workflow and patient wait times.

Appealing denied requests adds administrative burdens and delays essential care.

Inconsistent guidelines and unclear denial reasons make it difficult to address concerns effectively, lacking transparency in the prior authorization process.

Here are the common challenges associated with prior authorization:

The prior authorization process can be a significant challenge for healthcare providers. It typically involves submitting a request to the patient's insurance company, which includes the patient's medical diagnosis, proposed treatment plan with justification, and supporting medical records demonstrating medical necessity.

This process can be streamlined with the help of electronic health records (EHRs). EHRs can provide eligibility and formulary data, including prior authorization requirements, in the E-Prescribing workflow. This means users can complete only the required information without leaving their EHR.

Fast approval is crucial to support adherence, as it increases speed to therapy. This is especially important in today's healthcare landscape, where navigating the complexities of prior authorization can be a significant challenge.

Prior authorization workflows can be made more efficient with the help of integrated solutions. These solutions allow users to proactively initiate requests and receive quick responses. They also enable users to surface prior authorization responses within the workflow, so prescriptions can be processed sooner.

Here are some key benefits of integrated prior authorization solutions:

One health system was able to improve its pickup rate by six percentage points using an integrated prior authorization solution. This is a great example of how streamlined prior authorization workflows can lead to better patient outcomes.

Electronic Prior Authorization is gaining efficiency, with a 44% rise in prior authorizations processed electronically in 2022. This trend is expected to continue as more prescribers use EHRs equipped with Surescripts Electronic Prior Authorization, which now accounts for 84% of prescribers.

Organizations are leveraging Electronic Prior Authorization to streamline their team's processes and improve medication-related decision-making. This is especially true for health plans, PBMs, and pharmacies that have teams working directly with prescribers and health systems.

Electronic Prior Authorization can help payers supply up-to-date information through On-Demand Formulary and Real-Time Prescription Benefit inquiries. This enables prescribers to access a more accurate reflection of the need for prior authorization.

The Surescripts Prior Authorization Portal provides a fully electronic connection to PBMs, allowing prescribers to easily manage requests and submissions, and access timely approvals or other determinations. Thousands of prescribers and their staff use this portal to gain a more efficient workflow.

Here are the different types of organizations that can benefit from Electronic Prior Authorization:

To ensure that Electronic Prior Authorization is working efficiently, it's essential to have a next-generation prior authorization experience. This requires rapid shifts in organizational priorities, a digital operating model, and advanced technology capabilities.

Prior authorization solutions and services can help streamline the process, reducing administrative burdens and improving patient satisfaction. With the right tools, healthcare providers can focus on patient care.

According to the Council for Affordable Quality Healthcare’s 2021 CAQH Index, automating administrative processes could save the medical industry $437 million a year. This is achieved through a reduction in administrative costs, an increase in net promoter scores from providers and members, faster access to patient care, and lower denial rates due to transparency in coverage criteria.

Healthcare providers are turning to outsourced prior authorization services to improve efficiency and reduce denials. This approach offers several advantages, including increased efficiency, reduced denials, improved cost savings, and enhanced patient satisfaction.

Electronic Prior Authorization (ePA) solutions like Surescripts can make a huge difference in how health plans handle prior authorizations.

Surescripts transmits a dynamic electronic question set tailored to the medication from the benefit plan to the Electronic Health Record (EHR). This means that the questions asked are specific to the medication and the plan, making it easier for staff to enter the required clinical details.

Staff are guided through entering the required clinical details and, if necessary, submitting attachments. This streamlines the process and reduces the likelihood of errors.

You or your pharmacy benefit manager (PBM) can proactively prompt prescribers to initiate renewals, ensuring that patients don't run out of medication.

The Prior Authorization Portal allows call centers to ease the process even for those without an integrated solution. This means that patients can get the help they need, even if their health plan doesn't have a seamless ePA system in place.

With a fully integrated solution, your team can proactively initiate requests and receive quick responses within the EHR. This reduces delays and frustration, allowing patients to get their prescriptions faster.

Get responses sooner so patients spend less time waiting for their prescriptions. This is especially important for patients who rely on their medication to manage chronic conditions.

Surescripts helps vendors work more efficiently by streamlining prior authorizations. It automatically delivers requests to pharmacy benefit plans, reducing manual work and administrative burden.

Vendors can work with the plan if they receive denials or requests for more information. This helps resolve issues quickly and get patients the medication they need.

Eligibility and formulary data is provided in the E-Prescribing workflow, including prior authorization requirements. This helps vendors stay on top of requirements and avoid delays.

Benefit plans respond within the same workflow, allowing vendors to get quick approvals and reduce wait times. Fast approval increases speed to therapy, supporting patient adherence.

With Surescripts, vendors can proactively initiate requests and receive quick responses, making prior authorization workflows more efficient. This alleviates delays and frustration, and helps get prescriptions processed sooner.

Vendors can create routing rules for prior authorization tasks, allowing others to assist prescribers in managing requests. This helps ensure prescriptions are ready for patients when they go to the pharmacy.

The Prior Authorization Requirements, Documentation, and Decision (PARDD) API is a game-changer for healthcare providers. Beginning January 1, 2026, payers will be required to build and maintain a Fast Healthcare Interoperability Resources (FHIR) API that providers can use to determine if a prior authorization is required for a given item or service.

This API will facilitate the request and indicate request statuses, making it easier for providers to navigate the prior authorization process. The FHIR API will also enable providers to use the PARDD API to determine if a prior authorization is required for a given item or service.

The PARDD API will require insurers to include information about prior authorization decisions in Patient Access, Provider Access, and Payer-to-Payer APIs. This will help to improve interoperability and reduce administrative burdens for providers.

Here are some key benefits of the PARDD API:

The PARDD API is an important step towards streamlining the prior authorization process and improving patient care. By leveraging this API, healthcare providers can reduce administrative burdens and focus on delivering high-quality care to their patients.

Prior authorization regulations and requirements are becoming increasingly important in the healthcare industry. Insurers are being asked to include information about prior authorization decisions in various APIs, such as Patient Access, Provider Access, and Payer-to-Payer APIs.

This means that insurers will need to make sure their systems can share this information seamlessly with other healthcare stakeholders. This is a step towards greater transparency and efficiency in the prior authorization process.

Insurers will need to work closely with technology vendors and healthcare providers to ensure their systems can meet these new requirements. This will likely involve significant updates to their existing technology infrastructure.

Starting March 31, 2026, insurers will be required to publicly report certain prior authorization metrics.

Insurers will report how often patient data is transferred electronically, providing a level of transparency into the prior authorization process.

This change will give patients and providers a better understanding of how prior authorization is working in practice.

Real-world results are impressive, with some organizations finishing 10 electronic prior authorizations in the time it takes to finish one or two manually during a day.

Electronic prior authorization processes can save a significant amount of time, up to 45 minutes per medication authorization in some cases.

Public reporting is a crucial step in the prior authorization process. Beginning March 31, 2026, insurers will be required to publicly report certain prior authorization metrics.

Insurers will be required to report how often patient data is transferred electronically. This will help increase transparency and accountability in the system.

Public reporting will also help identify areas for improvement in the prior authorization process. By making this information publicly available, we can work together to streamline the process and reduce delays.

Starting in 2026, insurers will have to make this information easily accessible to patients and healthcare providers. This will enable us to track progress and make informed decisions about how to improve the system.

Prior authorization is a complex issue, and it's not just a problem for healthcare providers. Changes in federal policy are also affecting the industry, with two recent proposals from the Centers for Medicare & Medicaid Services aiming to streamline prior authorization processes for Medicare Advantage organizations, Medicaid managed care plans, and other entities.

In response to these changes, some states are taking matters into their own hands. At least 57 bills have been introduced in 22 states to reform prior authorization requirements for procedures, tests, treatment, and prescriptions.

State-level reforms are varied, but many proposals contain similar provisions, such as requirements on response time to requests, evidence-based prior authorization requirements, and mandates for insurers to publicly release data on prior authorizations.

Some states are also experimenting with "Gold Card" legislation, which would exempt physicians with high prior authorization approval rates from prior authorization requirements on specified services. Currently, Michigan, Louisiana, Texas, and West Virginia have enacted such laws.

Here are some of the types of provisions being proposed in state-level reforms: