Overcoming Prior Auth Challenges with Technology

The latest survey from the American Medical Association (AMA) reveals the challenges posed by prior authorization in healthcare. Prior authorization, a process health plans uses to manage healthcare utilization and control costs, has the potential to disrupt patient care, burdens physicians with administrative tasks, and wastes healthcare resources.

The Consequences of Prior Authorization

The AMA survey presents a stark picture of the impact of prior authorization on the healthcare system:

Patient Harm

• Nearly one in four physicians (24%) reported that prior authorization has led to serious adverse events, including hospitalization, permanent impairment, or death.
• A staggering 93% of physicians observed a negative impact on clinical outcomes.
• 94% of physicians noted delays in accessing necessary care, often resulting in patients abandoning their treatment due to struggles with health insurers.

Administrative Burdens

• Physicians complete an average of 43 prior authorizations per week, consuming about 12 hours of physician and staff time.
• Over a quarter (27%) of these requests are often or always denied, significantly contributing to physician burnout. In fact, 95% of physicians indicated that prior authorization significantly increases their burnout levels.

Download white paper: How to Ease Administrative Burdens, Boost Billing Accuracy & Speedy Payments

Wasted Health Resources

• An overwhelming 87% of physicians stated that prior authorization requirements lead to higher overall healthcare utilization. This includes the diversion of resources to ineffective initial treatments, additional office visits, urgent or emergency care, and hospitalizations, indicating significant waste rather than cost savings.

Read more: Top 5 Inefficiencies of Prior Authorizations and How Payers Can Overcome Them

The Call for Reform

These findings highlight the critical need for comprehensive reforms in the prior authorization process. The AMA strongly advocates for state-level reforms and supports federal legislation aimed at streamlining prior authorization procedures within Medicare Advantage. The goal is to prioritize patient access to care, reduce administrative burdens, and preserve resources for high-quality care.

In-Depth Survey Results

The latest “AMA Prior Authorization Physician Survey” underscores the persistent challenges physicians face with prior authorizations—a strategy payers use to ensure necessary treatments. However, the majority of physicians agree that this tactic does not benefit them or their patients.

• The survey, which included 1,000 practicing physicians (400 primary care and 600 specialists), revealed that 94% experience care delays due to prior authorizations, and 78% say that prior authorizations can sometimes lead to treatment abandonment.
• For some patients, these outcomes have severe consequences. Almost a quarter (24%) of respondents reported serious adverse events, including hospitalization (19%), life-threatening events (13%), and disability, permanent damage, or death (7%).

Read more: 5 Tips to Ease the Burden of Prior Authorizations

Administrative burdens are a significant concern as well. Physicians complete an average of 43 prior authorizations per week, with staff dedicating about 12 hours to this task. Some staff members work exclusively on prior authorizations. Moreover, 73% of physicians reported an increase in denials over the past five years, while only 3% saw a decrease. Despite the rise in denials, less than one in five physicians always appeal adverse decisions due to pessimism about success, the urgency of patient care, and insufficient resources.

Prior authorizations also lead to greater overall healthcare utilization, as reported by 87% of physicians. Ineffective initial treatments (69%) and additional office visits (68%) are primary contributors, with emergency department visits (42%) and hospitalizations (29%) also noted.

Read more: 11 Tips Payers Can Use to Automate & Streamline the Prior Auth Process

NantLink? — A Streamlined Solution

In response to these challenges, NantHealth introduced NantLink, an innovative EHR interoperability and point-of-care solution designed to automate provider workflows, reduce administrative burdens, and enhance the healthcare experience.

NantLink integrates seamlessly with Electronic Medical Record (EMR) systems, providing healthcare providers with direct access to insurance information within their EMR. This enables them to perform eligibility and benefits (E&B), claims, and authorization interactions from the system where they conduct most of their work. This technology enhances workflow efficiency, allowing providers to make informed decisions with a more holistic understanding of their patients’ medical history and potential risks. NantLink simplifies collaboration with health plans, making it easier for providers to work directly with them.

The findings of the AMA survey bring to light the urgent need for reform in the prior authorization process, which has long been a significant barrier to efficient and effective patient care. As the healthcare industry continues to evolve, it is crucial to adopt solutions that streamline administrative processes and prioritize patient outcomes. NantLink stands at the forefront of this shift, offering a streamlined, integrated solution that addresses the core challenges identified in the survey. By embracing such innovations, the healthcare industry can move towards a future where patient care is optimized, and administrative burdens are significantly reduced.

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