Prior Authorization Process Improvements

Prior authorization (PA) is a utilization management process used by some health insurance companies for determining if the patient’s health policy covers a prescribed services, like procedures, tests, or medications, before services are rendered. While intended to control healthcare costs, PAs can be a significant burden on healthcare providers and can delay patient care. Here are a few ways to improve the PA process:

• Streamline the process: Simplifying the PA process reduces administrative burdens on healthcare providers and improve patient access to care. This could include standardizing prior authorization requirements across payers, reducing the number of required forms, and implementing electronic prior authorization (ePA) systems.

• Utilize technology: ePA systems improves the PA process by automating the submission, review, and decision-making processes. This can reduce the administrative burden on providers and help speed up the approval process.

• Implement evidence-based guidelines: Using evidence-based guidelines to determine the appropriateness of a medical service or medication reduces the need for PAs. This can also help improve patient outcomes by ensuring that patients receive the most effective treatment.

• Increase transparency: Making PA requirements and decisions more transparent informs healthcare providers and patients for better understanding of the processes and the reasoning behind decisions. This can also help reduce confusion and frustration among patients and providers.

• Collaborate with healthcare providers: Working with healthcare providers to develop and implement PA policies ensures that policies are practical and effective. This can also help reduce the burden on providers and improve patient care.

For more information on improving the PA process, check out the following resources:

The American Medical Association’s PA Toolkit
The National Association of Specialty Pharmacy’s PA Best Practices
The Healthcare Financial Management Association’s PA Optimization Playbook