Under the stewardship of Administrator Chiquita Brooks-LaSure, the Centers for Medicare & Medicaid Services (CMS) has unveiled a final rule heralding crucial reforms in CMS prior authorization, aimed at slashing patient care delays and electronically streamlining processes for physicians. According to the U.S. Department of Health and Human Services (HHS), these collective changes are projected to deliver an estimated $15 billion in savings to physician practices over the span of 10 years.

The Problem of CMS Prior Authorization

CMS Prior authorization workflows have long been emblematic of inefficiency in healthcare, exacerbating care delays, compromising patient outcomes, and sowing frustration among payers, providers, and consumers alike. The predominant reliance on manual processing in most prior authorizations (PAs) between payers and providers has engendered decision timelines spanning from several hours to weeks, precipitating instances of deferred care, treatment abandonment, and even adverse patient events.

The 2022 American Medical Association (AMA) Prior Authorization Survey lays bare the gravity of these challenges, reporting a staggering 94% of respondents citing care delays and abandonment due to PAs, with 33% attributing these delays to adverse events, including fatalities, hospitalizations, or life-threatening emergencies. Against this backdrop, physician practices grapple with an overwhelming burden, completing an average of 45 PAs per physician weekly and dedicating approximately 14 hours to these tasks, with 88% of practicing physicians deeming the PA administrative burden as “high or extremely high.

The Need for Technology

Addressing the shortcomings of CMS prior authorization necessitates a concerted effort between payers and providers to dismantle technology silos. This strategic imperative extends beyond mere alleviation of manual processes; it encompasses enhancements to the timeliness and quality of care delivered to the shared consumer base. Automation solutions can be applied iteratively, either individually to streamline process steps or bundled to support holistic clinical recommendations.

The Role of NLP and AI

A primary obstacle in the realm of prior authorizations lies in the unstructured nature of data received by health systems. Despite electronic transmission, requests typically manifest as unstructured PDFs, posing challenges for payer systems in data ingestion. Manual data entry on the payer’s end often precedes review, compounding delays, particularly in urgent cases. Moreover, discrepancies stemming from manual entry errors and the variability of health plans’ CMS prior authorization rules further exacerbate the situation.

NLP and AI technologies, in tandem with robust integration engines, emerge as indispensable allies in streamlining prior authorization processes. By seamlessly converting unstructured PDFs—even handwritten documents—into formats compatible with payer systems, these technologies expedite decision-making, hasten specialist referrals, and facilitate access to treatment. Beyond efficiency gains, this approach safeguards continuity of care and fosters improved patient outcomes by ensuring timely access to appropriate interventions.

By leveraging the power of automation, Natural Language Processing (NLP), and Artificial Intelligence (AI), healthcare stakeholders can navigate the complexities of prior authorization with agility and precision, ensuring timely access to essential treatments and services. As we embark on this journey towards a more efficient and equitable healthcare system, let us remain steadfast in our commitment to driving positive change and fostering a future where every patient receives the care they deserve, when they need it most.