June 2021 | Point of View

Reduced burden, better experiences: Applying a data-driven mindset to prior authorizations

Payer organizations can improve the prior authorization process by shifting to a data-driven approach that generates actionable insights

Reduced burden, better experiences: Applying a data-driven mindset to prior authorizations

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.

Improve data hygiene and visibility with a standardized approach  

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.

Use that data to generate actionable insights linked to essential processes 

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:

  • Optimizing request reviews across accounts: Since many self-pay and admin-only accounts determine their own prior authorization requirements and processes, you need to have data standards in place that allow the data from these transactions to be meaningfully folded into your network data. Doing so will improve review processes, allowing teams to inform those medical services which should be on a prior authorization list from a selling and benefit perspective. 

    It also reduces the burden on providers, who are seeing patients across multiple products and carriers and for whom it’s difficult and time-consuming to try and memorize multiple prior authorization lists and/or make calls to payer organizations for validation.  
  • Informing care paths and follow-up workflows: Since prior authorizations are typically for single service requests, bundling new requests with previous requests is essential to creating and anticipating optimal care paths. Take, for example, an elective procedure that will require a set of follow-up skilled nursing visits. With standardized datasets in place, you’ll be able to auto-trigger follow-up workflows that extrapolate from historical activity at the point when the initial service is requested, thereby producing an inherently data-driven, proactive approach to utilization management that eases the burden on providers, patients, and UM staff. 
  • Improving member experience: Superior handling of prior authorizations can be a key tenet of your member experience and engagement initiatives. In the same vein as our two previous points, applying consistent approaches to standardized datasets will allow you to streamline processes and be more proactive in supporting and managing workflows. This, in turn, informs effective care management, which is fundamental to member experience. The better your organization is at identifying points of care transition and easing handoffs, the more trusted it will be by members and providers alike, all of which will ultimately lead to higher engagement rates and improved health outcomes.

Bottom Line: Take a data-driven approach  

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.

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