In the Summer 2024 edition of For The Record, Janus Health Chief Product Officer John Garcia discusses the common battle providers face with prior authorization and how automation can lessen the burden. Prior authorizations are widely used across payers to authorize coverage for treatments, drugs, procedures, surgeries, and more. If authorization is denied for necessary procedures, patient care can be jeopardized.
Although prior authorization was introduced to help control healthcare costs, it has become increasingly costly for providers to conduct. A 2023 American Medical Association survey found that health systems complete an average 43 prior authorizations per physician, per week1, requiring significant staffing to determine when an authorization is required, submit authorization materials, and check an authorization’s status. That same survey found that for 95% of physicians, the burden of prior authorization contributed to burnout.
There’s no silver bullet
In response to providers’ growing frustration, the Centers for Medicare & Medicaid Services (CMS) released the Interoperability and Prior Authorization Final Rule (CMS-0057-F) in early 2024, estimated to save providers, patients, and payers more than $15 billion over the next 10 years2. The final rule includes standards for prior authorization decision timeframes, response details, public reporting, and data exchange formats.
While this is a big step forward, the final rule has limitations, applying only to CMS-regulated health plans (i.e. not commercial plans) and to prior authorizations for procedures and services (i.e. not drugs). In addition, there are no standards for how payers make prior authorization decisions or for how they accept and respond to denial appeals3.
But there is hope for providers to level the playing field. Adding automation to key parts of the prior authorization process can ultimately make it less taxing. While there is no perfect solution, automation helps health systems significantly increase their prior authorization efficiency and capacity, which may ultimately improve write-offs downstream.
In his article, Garcia makes five recommendations to ensure prior authorization automation success:
- Understand your current resources to automate where it will provide the most support for your team.
- Free prior authorization services are payer-sponsored and may not align with your own goals, workflows, and payer mix.
- Know your payer mix and which payers are most challenging for staff to work with.
- Look outside your EHR for better coverage of your local or regional payer mix.
- Determine the specific prior authorization problem you are trying to solve.
Learn more about improving the prior authorization process and lessons learned from implementing automation in the Summer edition of For The Record.
