The Impact of Prior Authorizations on Patient Care

Today’s healthcare system is like a complex puzzle. Every piece represents a different entity, from hospitals and provider offices to health plans and third-party vendors. Each is characterized by its own unique systems and processes. I started my career in the healthcare industry more than a decade ago. My early involvement in system design and implementation gave me insight on the impact silos and fragmentation have on operations such as prior authorizations.

Health plans use prior authorizations, a component of utilization management, to ensure healthcare services are appropriate, medically necessary, and cost-effective. Although crucial for maintaining checks and balances, this process demands significant labor. Unlike typical healthcare transactions, prior authorization is far from a straightforward inquiry-and-response interaction. It’s a complex conversation that evaluates necessity against a member’s medical record and a health plan’s guidelines. Even today, there is a largely manual and burdensome nature to prior authorizations. Reviews can lead to delays in care and negatively impact the overall patient experience.

Statistics from the American Medical Association indicate that 94% of patients face care delays due to the burdensome prior authorization process. Undoubtedly, this has a profound influence on health outcomes. Delays also add stress to patients when they are already in need of care.¹ It wasn’t until I personally experienced the process that I comprehended the impact it has on patients’ well-being.

In 2022, I faced my own prior authorization ordeal. After unsettling news, I urgently needed a CT scan. Anxious to address the situation quickly. Securing the earliest available appointment, I came to realize later that I wasn’t sure if my prior authorization would be ready in time. Upon contacting my insurance company, I learned they used a vendor whose system couldn’t provide status updates beyond “pending.” The uncertainty added to my stress of dealing with potential health concerns, as I worried whether approval would come through in time or if I’d have to reschedule at the last minute, prolonging the process further. I just wanted a diagnosis!

Fortunately, I received approval in time and proceeded with my procedure. However, the additional stress and uncertainty surrounding the prior authorization process was unwelcome, especially during an already high-stress situation. Sadly, my experience is not unique. Every day, countless individuals anxiously await news on whether the treatment they require will be approved or denied. Experiencing the anxiety and uncertainty firsthand, and knowing others are enduring similar situations, fuels my dedication and passion for the work I do at Availity^® with our AI-powered prior authorization review solution.

As a strategic account services manager at Availity, I interact with clients daily. I can confidently say our products make a difference in the lives of those they serve. With Availity AuthAI™, patients are getting decisions on prior authorizations in seconds and at the point of care. The tool streamlines the prior authorization review process with a data-first workflow—collecting clinical data at submission. It then evaluates it against a health plan’s medical policies before recommending a decision or pending the request for further review. Automating up to 80% of the manual workload leads to a substantial decrease in administrative costs for payers. Additionally, it significantly reduces decision time.

If you’re interested in learning more about how Availity AuthAI leverages artificial intelligence, natural language processing, and clinical data to deliver data-driven decisions at the point of care, click here!

Author Bio:

Christine Furman, a Strategic Account Services Manager at Availity, brings more than ten years of specialized experience in managing customer accounts, conducting system assessments, designing solutions, overseeing implementations, optimizing processes, and fostering adoption within the healthcare industry. She seamlessly integrates technical proficiency with a profound comprehension of healthcare intricacies. Christine is committed to her vision of fostering a healthcare landscape free of obstacles, empowering individuals to prioritize their well-being without hindrances. She holds a Bachelor of Science degree in Chemical and Biomedical Engineering from Carnegie Mellon University,