Intelligently Automating Prior Authorization to Build Consumer Trust in Healthcare

Healthcare leaders are engaging us in a variety of discussions to explore intelligent automation’s role for complex business challenges, ranging from efforts to enhance consumer trust and use artificial intelligence (AI) in effective ways, to navigating change that comes with prior authorization mandates. This series shares key insights coming from those discussions.  

As the saying goes, diamonds are made under pressure, and the most impactful opportunities are often those that challenge leaders the most. 

Prior Authorization, In a Nutshell

The CMS Prior Authorization mandate, which goes into effect on January 1, 2026, aims to reduce guesswork for healthcare consumers and the administrative burden on care teams, and to improve patient/member care by streamlining processes and enhancing the exchange of health information. 

Enabling prior authorization through API development is a good start; however, APIs are not a comprehensive solution. Rather, the introduction of multiple third-party APIs creates new processes and steps, often prompting manual follow-ups to track and connect data gathered from multiple sources. In addition, these new data points require new data models and methods to handle patient data.  

To address these inherent challenges, healthcare leaders are prioritizing investments in interoperability and automation technologies. 

Intelligent Automation Supports Prior Authorization and Business Efficiencies

True trust-enhancing transparency can be unlocked through intelligent automation. This is especially true as low-code, more-approachable AI, machine learning (ML) and Generative AI (GenAI) capabilities enter the mix. 

Intelligent automation connects digital process automation (DPA), robotic process automation (RPA), and artificial intelligence (AI) to deliver efficient and intelligent processes and align all aspects of your organization with the vision of constant process improvement, technological integration, and increasing consumer value. 

Although DPA, RPA and AI don’t make final decisions, they can streamline and leverage information, so the right decision gets made. Health insurers are always seeking access to actionable information about their members while adhering to data privacy laws and regulations. 

Getting to that actionable data requires multiple considerations: 

• Using best practices to assemble and curate the right data fields for any given use case 

• A continuous process of identifying and resolving issues in core systems 

• Appropriate environments in which to store data to maintain its integrity, security, and accessibility 

• Only then can you effectively enable specific sub-functions (i.e. functions that ingest the data then act or recommend actions) to happen accurately and on time 

Streamline and Optimize Prior Auth Processes

Every step in the prior authorization process has potential for improvement using intelligent automation. It can support, enhance, and accelerate based on rules engines, event logs, decision rules, and simple automations of high-volume processes. 

These intelligent tools streamline information sharing between payers and providers, reducing the need for repeated exchanges and guesswork, enhancing clinical review, and ensuring timely, accurate decisions. 

Intelligent automation rapidly optimizes the prior authorization workflows that occur at the edge of what can conveniently and cost-effectively be managed through APIs. AI and machine learning (ML) can assist required communications, reporting, and decision flows in many ways, including: 

• Orchestration: Automate the coordination of tasks and data flow between disparate systems and stakeholders. 

• Monitoring: Continuously track the status of prior authorization requests and flag any issues or delays. 

• Standardization: Ensure consistent repeatable workflows and processes across all systems to facilitate smoother information exchange. 

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Best Practices to Transform Prior Authorization Experiences

Intelligent automation enhances and overlays existing systems, helping to accelerate the prior authorization process with greater efficiency and generating insights into any recurring root causes in process breakdowns. 

As you’re approaching your prior authorization initiatives, we recommend the following transformation best practices: 

Transformation Tip #1: Cross-Functional Feedback

Maintaining cross-functional feedback is essential to identify and address pain points effectively. Automation allows for healthcare providers to quickly identify and communicate common pain points, such as inaccurate or incomplete record keeping, avoiding common pitfalls in the prior authorization process. 

Transformation Tip #2: Measurement and Tracking

Automated processes provide valuable insights for contracting, reporting requirements, and more. By measuring and tracking these processes, efficiency, effectiveness, and consumer experience are greatly impacted. This information can be used to improve upstream messaging to patients and members about prior authorizations.  

The overlay of technology not only increases operational efficiencies, but it also provides valuable insights that can be used to improve communication and support for consumers. 

Empowering Solutions for Healthcare

We partner with healthcare leaders to optimize prior authorization experiences and drive transparent, consistent engagement with consumers.  

Interested in learning more? In a recent webinar, our experts explored how better prior authorization experiences could enhance consumer trust in healthcare. 

Discover why we’ve been trusted by the 10 largest healthcare systems and 10 largest health insurers and are consistently recognized by Modern Healthcare as a leading healthcare consulting firm. Contact us today to explore how we can help you forge better experiences and improve outcomes.

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