Article
Payer organizations can improve the prior authorization process by shifting to a data-driven approach that generates actionable insights
June 25, 2021
It’s no secret that the COVID-19 pandemic has intensified the essential challenges of a connected healthcare ecosystem, highlighting the various touchpoints among providers, payers, and patients. In a context of such heightened uncertainty and unprecedented challenges, administrative burden reduction has become more important than ever.
Attention has again turned to prior authorizations, with the publication of the AMA’s 2020 physician survey showing the vast majority (85%) of physicians continuing to rate the prior authorization burden as high or extremely high last year (the same rating was given by 86% in both 2019 and 2018).
Despite ongoing dialogue from both payers and providers around what might change with a process that’s often unpopular with providers and patients alike, the practice of prior authorizations (“requests”) will continue in the industry.
While perfect efficiency and the complete elimination of the prior authorization burden is not going to happen overnight, many healthcare payers are taking steps with their systems architecture and digital capabilities to support better go-forward strategies.
Ultimately, it’s about providing the easiest, least burdensome experience for patients and providers, both as a key aspect of a payer’s market differentiation tactics and as a move to greater operational efficiency. Data is key—innovative payers will not only effectively tap into unused data but also deploy analytics capabilities to surface insights in support of streamlined processes that ensure there is no impact to care.
Two key success factors of any successful move toward prior authorization burden reduction have emerged that payer organizations of any size and complexity can start with now.
Significant data is generated in a single prior authorization request, but not all of it is immediately usable. At minimum, there’s the basic set of information that comprises the request itself, as well as appended information from the review and approval process. Given that this constantly ongoing process typically involves numerous manual touchpoints, and that valuable clinical information is often in free-text formats, it’s easy to see how problems with data quality and accessibility can emerge. This also impacts downstream workflows, like those for referrals, which are reliant upon data integrity and the use of defined data fields.
That’s why merely capturing that wealth of prior authorization data isn’t enough; it needs to be standardized in order to be repeatedly retrievable and actionable. To those ends, an enterprise data architecture and governance model are essential. The resulting data hygiene and visibility will provide the groundwork to create visibility that improves your related business processes, directly impacting the bottom line.
Process improvement is the name of the game when it comes to prior authorization burden reduction. In our experience, a few broad categories of valuable business concerns stand to be positively impacted by the actionable insights derived from the structure and governance principles we outlined in the previous section:
Prior authorizations are here to stay, but as payer organizations mature their enterprise data structures and capabilities, they can begin to become more innovative and drive process-improving insights. Now is the time to act, as mandates continue to evolve and the industry is engaged in figuring out the best path forward.
Taking data-driven approaches to the wealth of information at your organization’s disposal—coupled with a digital-first mindset—will help create greater visibility and develop time and cost-saving standards. This is a must, and it includes identifying trends as part of population health management, improving utilization management and care coordination, creating differentiating member and provider experiences, or all of the above.
The healthcare industry is in a constant state of self-improvement, and prior authorizations are on the list of top priorities for both payers and providers when it comes to the future of utilization management.
Health payers have an excellent opportunity to drive the next step in the evolution of prior authorization process improvement, reducing a longstanding burden in support of a more proactive healthcare system that is more inclusive of changing technologies, regulations, workforce needs, consumer expectations, and financial models.
