Integrating prior authorization into clinical workflows cuts costs, speeds up decisions
Integrating prior authorization into clinical workflows can help cut costs while speeding up decisions, according to new research published Monday.
This utilization management tactic—requiring a payer’s OK before a healthcare service proceeds—disproportionately affects specialties such as diagnostic radiology and cardiology. Radiation oncology faces a particularly heavy burden, experts detailed in JAMA Network Open. Despite its high cost-effectiveness, prior authorization is used in over half of cancer cases involving RT, even though the specialty only accounts for 4% of annual cancer spending.
Radiation oncologists with Northwell Health in New York recently experimented with integrating prior authorization rulings into physicians’ daily workflows, hoping to improve transparency and reduce their administrative burden. The pilot appears to be paying off, producing a more than 65% reduction in care denials.
“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,” lead author William C. Chen, MD, a radiation oncologist with Northwell, and colleagues wrote Dec. 22.
Researchers implemented the new workflow at three facilities including a suburban satellite site, primary academic center and another urban outpost in 2024. They utilized a prior authorization support and automation software called InsightRT, with some of the authors reporting receiving payments from the manufacturer, Siris Medical. They included study co-author and Siris CEO Colin Carpenter, PhD, who also is chief scientific officer of parent company TurningPoint Healthcare Solutions, Lake Mary, Florida. Authors compared the results against four other Northwell healthcare sites that functioned as controls in the experiment.
The streamlined new workflow leverages software for the following key steps in the prior authorization process:
- Listening for new treatment orders in the practice management system or EHR to automatically initiate the authorization workflow.
- Identifying the payer and retrieving the necessary documentation for the submission.
- Leveraging the clinical details and providing the care team with an assessment against payer policy to predict the likelihood of an approval.
- Notifying the clinical team of the authorization’s status.
Chen and colleagues noted the software retrieves specific clinical data elements commonly required for payers in prior authorization submissions. These include (but are not limited to) diagnosis codes, staging, additional treatments, and radiation prescription parameters like technique, fractionation dose and imaging guidance. Missing elements are then flagged for manual entry by clinical staff.
“The software operates as a rules-based system, not using artificial intelligence, and does not incorporate or predict actual treatment-plan information (e.g., dosimetric outcomes, treatment volumes) nor suggest treatment modalities,” Chen et. al reported.
A total of 86 different health plans cover the patient population studied, with seven dominant payers. Across over 6,550 radiation oncology cases (2,400 in the intervention group), implementation of the software was associated with a 65.4% average reduction in prior authorization denials (from 314 [7.6%] down to 63 [2.6%]) across all health plans. Per payer, the denial decrease ranged from 45.7% to 88.6%. Payer and practitioner prescription alignment occurred in 97.4% of cases, and the median authorization time decreased by 33.9%.
A follow-up survey of 15 users, including 7 physicians and 8 billing staffers, reported increased satisfaction relating to speed, transparency, ease of use and overall experience.
In a corresponding editorial, Vanderbilt University radiation oncologists highlighted the study’s strengths including its large dataset and statistical validation across payers and disease sites. The latter potentially supports the salability of the intervention, and the inclusion of user satisfaction data “adds an important humanistic dimension.”
However, the editorialists also flagged several potential limitations, noting payer policies are not always aligned with up-to-date evidence nor expert recommendations. This presents risk an automated prior authorization tool could “discourage busy physicians from pursuing treatments justified by medical evidence but deemed unlikely to be approved without the work of a lengthy appeal process.” However, the authors evaluated prescriber patterns before and after implementation and found no significant differences, deeming it did not impact clinical decision-making.
“Chen et al. provide compelling evidence that clinically integrated [prior authorization] software can streamline processes, enhance clinician satisfaction, and reduce care delays in radiation oncology,” Evan C. Osmundson, MD, PhD, and colleagues wrote. “While such tools represent a substantial step forward, broader reforms are needed to address the underlying structural asymmetries between payers and clinicians that no software alone can fully resolve.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.