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 characterized by its own unique systems and processes. When I started my career in the healthcare industry 10 years ago, my early involvement in system design and implementation gave me firsthand insight on the impact silos, fragmentation, and manual process have on healthcare operations such as prior authorizations.

Health plans use prior authorizations, a component of utilization management, to help 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 medical necessity against a member’s medical record and a health plan’s guidelines. The largely manual and burdensome nature of prior authorization 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, which can have a profound influence on health outcomes and adds stress to patients when they are already in need of care.¹ Although I reviewed data on care delays while working in healthcare, it wasn’t until I personally experienced the prior authorization process that I fully comprehended the substantial impact it has on patients’ physical and mental well-being, especially while waiting for approval or denial.

In 2022, I faced my own prior authorization ordeal when I urgently needed a CT scan after hearing unsettling news from my doctor. Anxious to address the situation quickly to understand what was happening in my body, I scheduled the earliest available appointment, only 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 to get 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 can confidently interact with clients knowing our products make a difference in the lives of those they serve. With Availity AuthAI™, I know that instead of waiting days to get answers, patients are getting decisions on prior authorizations in seconds and at the point of care. Availity AuthAI streamlines the prior authorization review process with a data-first workflow—collecting clinical data at submission and evaluating 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, as well as a significant reduction in the time patients spend awaiting a decision.

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, serving as the Strategic Account Services Manager at Availity, offers 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. Holding a Bachelor of Science degree in Chemical and Biomedical Engineering from Carnegie Mellon University, 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.