The Burden of Prior Authorization on Patient and Provider

Understanding and navigating the insurance process within the healthcare industry is cumbersome. Healthcare providers have to spend several hours a week updating files, checking compliance, and most importantly, submitting requests. Patients need to have insurance with a wide range of coverage or face devastating charges for medical care.

One more specific example of the challenges of the insurance process comes in prior authorization. Typical health insurance will cover a variety of commonplace services and care. However, for more specific treatments or coverage, a request for the insurance to cover the service has to be submitted. This process of a healthcare provider submitting a request for insurance coverage is called prior authorization.

On the surface, this is a practice which is meant to save insurance companies money and time. Instead of having to specify the coverage of every service, healthcare providers will just submit a request for more niche services. However, what this leads to in practice is a heavy administrative burden on these healthcare providers.

93% of physicians today say prior authorization creates a “high” or “extremely high” administrative burden. In practice this leads to about a third of providers hiring staff to take on this burden. Yet not every provider can afford this, and currently there is a massive shortage of staff in the healthcare industry.

What this means for patients is that essential or sometimes life-saving care can be delayed or entirely denied. It’s not financially realistic to have care uncovered, but without prior authorization going through it can become the only option. These are the burdens that prior authorization can cause.

Fortunately, steps are being taken to reduce the likelihood of this happening. Some companies are trying to make prior authorization less needed. Mostly though, prior authorization process automation submission processes are easing the burden. If an AI service can check files, make calls, and submit requests, this saves countless hours, dollars, and lives.

The system itself is still in need of revision, but at least for now the burden has ways to be offset. If not through an employee, then through a program. Healthcare access and cost remains one of the biggest barriers to care today. Ensuring that administrative tasks aren’t growing that barrier is a big step in helping people get the care they need.