Case Study: From Bottleneck to Breakthrough: How Health Plans are Automating Prior Authorization with HealthEdge®
Learn about HealthEdge's Automated Prior Authorization solution, developed by the Global Professional Service team.
From Bottleneck to Breakthrough: Automating Prior Authorization with HealthEdge®
The prior authorization process is a critical function for health plans, designed to ensure that care is covered and qualifies for payment. However, in practice, manual prior authorization is often a time-consuming and burdensome process that can delay member care and increase administrative costs. Providers and their staff spend significant time on these requests—an average of 16 to 24 minutes per authorization, according to the 2024 CAQH Index Report.
HealthEdge® has developed an automation-led solution that transforms the prior auth process from a complex bottleneck into a streamlined, efficient, and value-driven operation.
The Challenge of Manual Prior Authorization
Traditional prior authorization workflows present significant challenges for health plans due to their complexity and reliance on manual intervention. Each request must be validated against a matrix of data points, including benefit plan details, service codes, eligibility, and provider contracts.
Key operational hurdles include:
- High Administrative Burden: Manual reviews are time-intensive, with a single routine request often requiring review from multiple team members.
- Data Management Complexity: Most legacy systems struggle to support the high volumes of data needed to process authorizations efficiently.
- Vendor Management Inefficiencies: Many health plans use multiple utilization management (UM) vendors. Manually updating the "vendor crosswalk" to route requests correctly can take weeks and incur substantial costs, leading to misrouted submissions and care delays.
- Provider and Member Dissatisfaction: Slow turnaround times and cumbersome processes create frustration for providers and can negatively impact the member experience.
For a deeper dive into overcoming these challenges, explore our resources on prior authorization strategy and automation and the importance of modernizing prior authorization.
The Solution: HealthEdge’s Automated Prior Authorization Platform
To address these challenges, the HealthEdge Global Professional Services team developed a centralized, high-volume, and easily configurable platform for automating prior authorization decisions. This solution serves as a single source of truth for authorization criteria, enabling real-time, automated decision-making.
Core Capabilities:
- Centralized Repository: Manages benefit plans, service codes, and authorization criteria in one place.
- High-Volume Scalability: Engineered to handle massive volumes of data without performance degradation.
- Real-Time Decision Automation: Instantly processes and approves requests that meet predefined criteria.
- Dynamic Vendor Crosswalk: Provides a crosswalk to ensure authorization requests are routed accurately to the correct UM vendor system.
- Simplified Updates: Allows end-users to update routing rules and other criteria by simply uploading a file, eliminating the need for costly and time-consuming IT development cycles.
Our GuidingCare® Utilization Management solution, supported by the GuidingCare Authorization Portal, provides the foundation for this powerful automation.
Real-World Impact: Case Studies in Automating Prior Authorization
HealthEdge's platform delivers measurable improvements in efficiency, cost savings, and satisfaction. See how we helped Priority Health ease healthcare preauthorizations and explore the following real-world examples.
Case Study 1: Automating Routine Authorizations for a Large Regional Health Plan
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Before |
After |
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Process |
A four-person UM team spent 40 minutes of combined staff time manually reviewing each routine request. Unnecessary submissions for services not requiring prior auth clogged the queue. |
The plan identified and eliminated submissions for service codes that did not require prior authorization. The system instantly auto-approved requests that met all predefined criteria. |
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Results |
40 minutes saved per auto-approved request. Real-time decisions improved provider satisfaction, and lower call volumes freed staff to focus on complex cases. |
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Case Study 2: Preventing Misrouted Authorizations at a Multi-State Plan
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Before |
After |
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Process |
The plan used multiple UM vendors, and updating routing rules was a manual process that took weeks and cost thousands. Misrouted requests bounced between systems, delaying care. |
A dynamic vendor crosswalk was introduced to recognize and immediately redirect requests to the correct vendor. Updates could be made in real time by uploading a new file. |
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Results |
Routing delays were eliminated. The vendor crosswalk rule update cycle was cut from six weeks to a few hours, improving provider trust and transparency. |
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Case Study 3: Gold Carding High-Performing Providers at a National Plan
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Before |
After |
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Process |
Even the most trusted, high-performing providers had to submit prior authorizations for routine services, creating unnecessary paperwork and delays. |
The "gold carding" feature was enabled, granting pre-approved access for certain services based on provider performance. Requests from these providers were automatically approved in real time. |
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Results |
Authorization turnaround time was reduced to same-day or instant for Gold Card services. Rule updates were deployed in under 24 hours, improving provider retention and member satisfaction. |
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A Strategic Opportunity for Health Plans
Automating prior authorization is more than an operational improvement; it is a strategic imperative. As regulatory requirements evolve, such as those outlined in the New CMS Proposed Rule on Interoperability & Electronic Prior Authorization, health plans must adapt. Embracing automation allows plans to turn compliance mandates into a strategic opportunity to enhance efficiency and care delivery.
By centralizing and streamlining the prior authorization process, health plans can achieve:
- Reduced Turnaround Times: Decrease decision times from days to minutes.
- Lower Operational Costs: Make significant cuts in administrative expenses.
- Improved Provider Relations: Increase provider satisfaction and retention by reducing their administrative burden.
- Enhanced Member Care: Eliminate bottlenecks to ensure members receive necessary care faster.
To further accelerate intake and reduce manual work, health plans can also leverage HealthEdge’s AI and intelligent OCR platform to digitize and process faxed or emailed requests.
By leveraging HealthEdge's advanced automation capabilities, health plans can build a foundation for a scalable, efficient, and compliant care management ecosystem that is faster, fairer, and more member-focused.
