Can Prior Auth Become an Ally & Transform Patient Care?

Prior authorization, the process of getting explicit approval in advance from a health plan for a test, medication, or procedure, is an ominous phrase to physicians and patients. Prior authorization represents red tape—hours on hold, endless forms and documentation to file—and the delay or occasionally even denial of care that the physician has deemed appropriate.

But what if instead of an obstacle, we could find a way to make prior authorization an ally?  What if we could use prior authorization to optimize the patient’s care journey?  What if health plans not only approved the initial care request, but partnered with the physician to make sure the patient is receiving other evidence-based care—behavioral health, home care, the right medical equipment— to insure the best outcome at the lowest cost?  What if we transformed prior authorization into the beginning of a partnership between health plan and physician to achieve true patient-centered care?

Accelerating the use of the latest technologies, AI and ML techniques, and advanced analytics is the path toward that reality. But what does that path look like?

First we need to accomplish the streamlining long advocated by the American Medical Association and increasingly appearing in legislative and regulatory mandates:

• Digitization. The vast majority of prior authorization requests can, and should, be processed electronically in real time. 
• Automation. The clinical review of prior authorization should be automated as much as possible. 
• AI-assisted reviews. For the small number of cases that can’t pass the initial automated process, we can apply artificial intelligence to achieve a second level of “auto-determination”: detecting special circumstances that might justify an approval even when a care plan deviates from the guidelines.  
• Physician “Goldcarding”.  Clinicians who follow evidence-based guidelines and consistently deliver excellent care should have a lower burden of prior authorization than those who don’t consistently follow the evidence. Smart, dynamic algorithms can give an express pass to the first group, while diverting the second group through a prior authorization “toll booth.” 

Building on that foundation, we can leverage advances in artificial intelligence and machine learning to create opportunities to drive even greater value–for health plans, physicians and patients–at every step of the care journey. We discuss what some of these advances look like and how they can deliver this value in our recent white paper: A needed transformation: changing prior authorization from an obstacle to a cornerstone of better care. Click here to download a copy and read it today.