Getting started with prior authorization automation

Prior authorizations are an essential part of today’s healthcare system, but they are also a source of friction in many healthcare organizations. 93% of physicians report that the traditional prior authorization process delays access to necessary care, and 82% report that the process can lead to patients abandoning their recommended course of treatment. 

Not only does this impact patient outcomes, but inefficient prior authorization processes also add to administrative burden for healthcare staff, often leading to ineffective initial treatments, additional office visits, and even urgent or emergency care for patients. The AMA reports that 88% of physicians say that burdens associated with prior authorizations are high or extremely high, and nearly two in five physicians employ staff members to work exclusively on tasks related to prior authorizations. 

Staffing inefficiencies, claim denials, and patient leakage put your healthcare system’s financial stability at risk. How can you reform your prior authorizations process to shorten turnaround times, decrease denial rates, and save staff hours? 

The answer lies in automation.

The traditional prior authorization method

The standard approach to prior authorizations is highly manual and inefficient. Clinical and administrative teams must: 

• Review charts to gather supporting documentation
• Submit requests through payer portals or fax
• Track down approvals or denials by phone or email 
• Re-submit or appeal when denials occur 
• Monitor lengthy lists in workqueues to avoid missed deadlines

Siloed front-to-back teams, disconnected legacy systems, and high staff churn only add to the operational friction in prior authorization workflows. 

Automated prior authorizations

Prior authorization workflows can be completely transformed by automation, letting AI Agents handle the straightforward cases and involving human staff only in more complex situations. 

An automated prior authorization workflow looks like: 

1. Data collection: An AI Agent extracts the necessary structured and unstructured data from the EHR to support a prior authorization request (but only what’s needed — never more). This includes gathering relevant clinical documentation, patient eligibility details, and procedure codes. 
2. Prior authorization submission: Once all required information is collected, an AI Agent automatically initiates and submits the prior authorization request to the appropriate payer through the correct channel—whether API, 278 transaction, portal, or fax. AI Agents ensure each submission follows payer-specific requirements and workflows.
3. Clinical authorizations support: For complex cases, such as those requiring detailed medical necessity documentation, Intelligent Agents review patient charts to ensure that appropriate clinical evidence is included with the submission. They also act as support for your staff as they submit the request. This reduces the risk of denials due to missing or incomplete data and helps staff submit high-quality requests more efficiently.
4. AI-generated responses to payer questions: When payers request additional information, AI Agents analyze patient data, including structured EHR fields and unstructured clinical notes, to generate accurate, evidence-backed responses. This minimizes errors, shortens response cycles, and reduces provider back-and-forth.
5. Clinical document packet generation support: AI Agents also assist in compiling full clinical documentation packets, analyzing patient history to gather relevant data. This accelerates packet creation and ensures submissions are complete and well-supported. 
6. Reauthorization requests: AI Agents manage renewal or extension requests by tracking care timelines and submitting reauthorizations as needed. 
7. Authorization status checks: In order to reduce manual follow-up by staff and to flag delays or denials early, Intelligent Agents continuously check the status of submitted authorizations across payer portals and update the EHR accordingly.
8. Workqueue cleanup: The system proactively cleans up authorization workqueues by removing false positives, duplicates, and outdated entries to maintain efficient workflows.

Once an authorization is approved, an AI-powered platform can also deploy AI Agents to proactively reach out to the patient to schedule follow-up appointments, providing cross-functional support for your care team and making it as touchless of an experience as possible. 

The benefits of automating prior authorizations

Automating prior authorization workflows has countless benefits across your revenue cycle and wider organization, including: 

• Faster turnaround times: Authorizations can be submitted and followed up around the clock, preventing unnecessary care delays and streamlining revenue capture. 
• Fewer denials: Intelligent Agents ensure submissions are accurate and complete before submitting, reducing downstream claim issues.
• Improved revenue capture: Authorized services are delivered more consistently, and denials are resolved or appealed faster, so less revenue slips through the cracks.
• Increased patient and staff satisfaction: Automation eliminates repetitive, manual tasks that consume valuable staff time. By accelerating approvals and reducing delays, it also helps ensure patients receive timely care. The result: care teams can focus on patients, not paperwork, and patients get the care they need, when they need it—it’s a win-win.

Healthcare organizations across the country are already seeing these positive outcomes in action. Fort HealthCare’s ambulatory surgery center was struggling with mounting prior authorizations, with several weeks of backlog waiting to be submitted, delaying patient care. By automating the process through Notable’s AI Platform, 91% of prior authorizations submitted today are successful, and 15 minutes are saved per successful submission.

Care New England needed to hire 14 additional FTEs to keep pace with the backlog of work. Instead, the hospital system automated its authorization process, resulting in a 55% reduction in authorization-related write-offs and a savings of 2,841 hours for staff.

Since going live with automated authorizations, MUSC Health has seen a 35-45% completion rate in touchless submissions on in-scope authorizations, meaning over one-third of its authorizations are successfully submitted without human intervention.

Five steps to get started automating prior authorizations 

Like any other technology, implementing automation can seem intimidating. Here are five clear steps to get the process started: 

1. Identify key use cases: Focus on high-volume or high-denial areas causing backlogs in your organization, prioritizing workflows that place the greatest burden on your staff.
2. Audit your current process: Map out how authorizations are handled in your organization today, including submission, tracking, reauthorizations, and appeals. Identify where delays and errors frequently occur. 
3. Choose the right partner: Partner with a healthcare automation platform that offers end-to-end support, including clinical data extraction and payer submission. 
4. Start small, then scale: First, implement automation for a select service line or payer. Make any necessary iterations, validate outcomes, and then expand to other specialties or sites of care once you’re ready.
5. Measure and optimize: Track key results like turnaround times, denial rates, and staff hours saved. Use these insights to continuously improve performance, ensure scalability, and celebrate the wins, showing what AI can achieve in your organization. 

Automating prior authorizations doesn’t just streamline a traditionally burdensome process, it empowers your team to deliver faster, higher-quality care. By starting small and scaling strategically, your organization can unlock significant efficiencies, reduce costs, and improve the experience for both patients and staff.