The prior authorization (PA) process healthcare providers endure is a story of unintended consequences. Created as a utilization management tool for healthcare insurance companies to control costs and protect patients from surprise bills, it has increasingly created heavy administrative burdens, increased claim denials and rework, and delays in care for patients. Medicare Advantage (MA) plans have become notorious for their high denial rates. The share of all PA requests that were denied by MA plans increased from 5.7% in 2019 to 7.4% in 2022i. PA process challenges, whether related to commercial or government coverage, have a negative impact on providers’ financial performance and cause unnecessary stress for billing teams and patients alike.
