Intelligent prior authorization: A shield against cardiovascular risk

Cardiovascular disease (CVD) remains the leading cause of death in the United States, impacting nearly half of American adults, yet only one in three adults received care for cardiovascular conditions or risk factors in 2020. The American Heart Association forecasts that the economic burden of cardiovascular conditions will nearly quadruple–from $393 billion to $1.49 trillion–between 2020 and 2050. With a growing prevalence of risk factors like obesity, diabetes, and hypertension, the burden of CVD continues to grow. Improving the efficiency and effectiveness of cardiovascular care and disease prevention is critical to addressing the increasing costs of CVD.

A key challenge in cardiovascular care is navigating complex and often chronic conditions. Fragmented coordination among primary care physicians, cardiologists, and other specialists can lead to delays in care, unnecessary and/or excessive testing, and poor adherence to long-term care plans. Health plans, in turn, also struggle to balance costs and benefits due to limited clinical data across multiple providers, making it difficult to manage chronic conditions effectively. Traditional prior authorization processes add to these inefficiencies, creating administrative bottlenecks that delay care and frustrate providers and patients. However, advancements in intelligent prior authorization and cardiology care offer a path to overcoming these obstacles.

The impact of fragmentation in cardiovascular care

Managing cardiovascular conditions like diabetes, hypertension, and CVD often requires input and coordination from multiple providers across specialties. Unfortunately, such care is frequently disjointed. Disparate departments try to piece together the data from misaligned communication and inconsistent use of evidence-based guidelines. These inefficiencies can lead to the selection of inappropriate diagnostic services and delays, which can worsen patients’ outcomes. For example, a patient experiencing early symptoms of coronary artery disease might encounter delays in receiving stress tests or angiography due to unclear approval pathways.

AI-driven prior authorization solutions address these challenges by automating approvals, streamlining traditionally burdensome processes, and ensuring care is aligned with current evidence-based guidelines. AI and clinical intelligence facilitate real-time decision-making, enabling providers to identify the appropriate diagnostic service and setting, collaborate more effectively, and focus on delivering timely care. This approach helps ensure patients receive the most appropriate, effective, and high-quality care, improving their overall care journey and outcomes.