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

Area of Science:

• Health Informatics
• Oncology Care Management
• Health Services Research

Background:

• Utilization management strategies like prior authorization aim to balance care appropriateness with cost.
• However, these processes can create administrative burdens, delaying patient access to necessary treatments, particularly in complex fields like oncology.

Purpose of the Study:

• To evaluate the impact of clinically integrated prior-authorization software on denial rates, authorization times, and staff satisfaction within an academic radiation oncology practice.

Main Methods:

• A quality improvement study comparing three intervention centers using prior-authorization software against four control centers.
• Data included 6551 radiation oncology cases across 86 health plans.
• Primary outcomes were denial rates and authorization times; staff satisfaction was assessed via surveys.

Main Results:

• The software was associated with a 65.4% reduction in prior authorization denials (7.6% to 2.6%) and a 33.9% decrease in median authorization time (4.2 to 2.8 business days).
• Payer-specific denial reductions ranged from 45.7% to 88.6%, and authorization time reductions varied by payer.
• Staff surveys indicated increased satisfaction with speed, transparency, and ease of use.

Conclusions:

• Real-time, clinically integrated prior-authorization software streamlines workflows and improves access to care.
• This technology demonstrates potential for reducing denials, expediting treatment, and enhancing practitioner satisfaction in radiation oncology.