Integrating Prior Authorization Into Clinical Workflows for Care Access and Practitioner Experience

Utilization management strategies such as prior authorization are used to balance appropriate care with cost but can create substantial administrative burdens that can delay timely access to necessary care. A real-time, clinically integrated prior-authorization process may reduce burden and expedite care, especially for complex diseases such as cancer.

To evaluate the association of clinically integrated prior-authorization software with denial rates, authorization times, and staff satisfaction.

This quality improvement study spanned from January to December 2024, with intervention data collected from August 2023 to December 2024. The study was conducted in a large, multifacility academic radiation practice within a major metropolitan network. Participants included physicians, nurses, and billing staff at the intervention sites. The patient population was covered by 86 health plans, primarily 7 dominant payers (4 national and 3 regional).

Three centers implemented the prior-authorization software, while 4 others served as control centers.

The primary outcomes were prior-authorization denial rates and authorization times. Staff satisfaction with the prior-authorization process was assessed through preintervention and postintervention surveys. Denial statistics were compared using the Fisher exact test, and timing statistics were compared using an unpaired t test.

Among 6551 (2403 intervention and 4148 historic control) cases from a radiation oncology patient population, implementation of the software was associated with a mean 65.4% reduction in prior authorization denials (from 314 [7.6%] to 63 [2.6%]; P < .001) across all payers. Per payer, the denial decrease ranged from 45.7% to 88.6%. Payer and practitioner prescription alignment occurred in 2340 of the 2403 intervention cases (97.4%). The median (IQR) authorization time decreased by 33.9% (from 4.2 [1.7-2.4] to 2.8 [2.4-3.0] business days; P < .001), with 18.9% to 52.3% payer-specific reductions; the 90th percentile reported an approximately a 1-week reduction (from 17.7 to 10.5 business days). Surveys of 15 users (7 physicians and 8 billing staff) reported increased satisfaction regarding speed, transparency, ease of use, and overall experience.

In this quality improvement study of prior authorization workflows, real-time transparency available at the point of care was associated with reduced rates of denials, reduced delays in care, and improved practitioner satisfaction. These findings suggest that such technology may offer a valuable solution to current challenges in prior authorization by streamlining workflows and facilitating more timely access to care.