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3 Problems Still Facing the Prior Authorization Process

We've written before about the changes we’re seeing in prior authorization and the work that is happening to digitize the process. But as we continue to grapple with the effects of the pandemic, it’s made us take a step back and ask if these changes are enough, especially as we see how quickly patient needs have changed in the last year or so.


With the world moving towards streamlining and optimization, the prior authorization process as a whole still seems woefully behind comparatively. While we’re seeing innovations within the space, is that pace enough to support changing needs of patients?


Lack of continuity in care

One of the main flaws that we’ve consistently seen in the prior authorization process is a lack of continuity in care for patients. Rather than simplifying the process and reducing the administrative burden for patients, the current prior authorization processes in place do the exact opposite.


In particular, for patients dealing with chronic health conditions, the lack of care has meant disruption and the fear of the unknown when it comes to prior authorization.


Every time patients switch to a different healthcare provider or insurance, worry and fear are constant, and the lack of continuity in care can add stress to an already challenging time for patients. A streamlined prior authorization process that reduces delays and works efficiently can do a great deal in ensuring that the patient experience remains the top priority.


One-size-fits-all processes

Another issue that continues to face prior authorization is a one-size-fits-all process. This applies to not just patient care but also for medication and treatment delays. There has been an increasing focus on reducing the role of prior authorization in services and medications that are usually approved or where the process does not bring value.


Instead of applying the process to each case without taking into account individual circumstances and clinical data, prior authorization processes that are currently in place complicate things. Decision support in this context is vital to ensure that the prior authorization process is optimized to make the right decisions quickly while factoring in clinical data and criteria to make the best decision possible.


Zero automation

Tying both these points together, the role of automation in prior authorization has not been explored as much as it should be. It’s clear that the process is fraught with manual work and administrative burden for both payers and providers, even though automation could significantly reduce this burden. Physicians should be able to view requirements and submit requests from their EHRs without undertaking a host of manual duties to accomplish this.


And on the patient side, there should be more transparency and automation to ensure that patients can access their data and any decisions regarding prior authorization easily. Automation allows for all of this and makes the prior authorization process far more transparent for both payers and providers.


We know that the prior authorization process has far more issues than the ones explored today, but that’s precisely why it’s so vital that the process sees a change. We know that the CMS ruling, “‘Improving Prior Authorization Processes and Promoting Patients’ Electronic Access to Health Information,” is the first step towards this, but there is more work to be done towards digitally transforming the prior authorization process.



At Banjo Health, we’re transforming the prior authorization process. Our solution is powered by artificial intelligence and designed by clinicians to make the prior authorization a better process for both payers and providers. To learn more about work in the prior authorization space and how we’re changing healthcare, get in touch today!

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