# Prior Authorization Issues * **Definition:** Challenges or complications that arise during the process of obtaining prior authorization from a health insurance provider before a patient can receive specific medical services, procedures, or medications, often leading to delays in care, increased administrative burden, and potential denial of coverage. * **Taxonomy:** Healthcare Topics / Prior Authorization Issues ## News * Selected news on the topic of **Prior Authorization Issues**, for healthcare technology leaders * 1.1K news items are in the system for this topic * Posts have been filtered for tech and healthcare-related keywords | Date | Title | Source | | --- | --- | --- | | 5/21/2025 | [**From hours to minutes: AI transforms MetroHealth's pharmacy prior authorization process**](https://www.beckershospitalreview.com/pharmacy/from-hours-to-minutes-ai-transforms-metrohealths-prior-authorization-process/) | [[Beckers Hospital Review]] | | 5/16/2025 | [**How Payer-Provider Collaboration is Creating A More Patient-Friendly Healthcare Industry**](https://hitconsultant.net/2025/05/16/how-payer-provider-collaboration-is-creating-a-more-patient-friendly-healthcare-industry/) | [[HIT Consultant]] | | 4/7/2025 | [**What Issues Do Healthcare Leaders Want Dr. Oz to Tackle as CMS Administrator?**](https://medcitynews.com/2025/04/what-issues-do-healthcare-leaders-want-dr-oz-to-tackle-as-cms-administrator/) | [[MedCity News]] | | 2/24/2025 | [**careviso and XiFin Form Strategic Alliance to Modernize Prior Authorization -**](https://hitconsultant.net/2025/02/24/careviso-and-xifin-form-strategic-alliance-to-modernize-prior-authorization/) | [[HIT Consultant]] | | 2/19/2025 | [**careviso and XiFin Announce Strategic Alliance to Modernize Prior Authorization and Revenue Cycle Management to Speed Reimbursement and Improve Patient Access**](https://www.prnewswire.com/news-releases/careviso-and-xifin-announce-strategic-alliance-to-modernize-prior-authorization-and-revenue-cycle-management-to-speed-reimbursement-and-improve-patient-access-302380329.html) | [[PR Newswire]] | | 2/10/2025 | [**Health Equity eekly Roundup: February 10, 2025**](https://www.ajmc.com/view/health-equity-access-weekly-roundup-february-10-2025) | [[AJMC]] | | 2/4/2025 | [**Why are pharma, medical device and DTx companies investing in telemedicine?**](https://www.healthcareitnews.com/news/why-are-pharma-medical-device-and-dtx-companies-investing-telemedicine) | [[Healthcare IT News]] | | 1/13/2025 | [**Sun Knowledge Inc. Gears Up for the Launch of Its Revolutionary SDP Platform**](http://prsync.com/sun-knowledge/sun-knowledge-inc-gears-up-for-the-launch-of-its-revolutionary-sdp-platform--4552264/) | [[PRSync]] | | 1/9/2025 | [**Availity, Concert Partner to Digitize and Automate Prior Authorization for Genetic Testing**](http://www.businesswire.com/news/home/20250109507578/en/Availity-Concert-Partner-to-Digitize-and-Automate-Prior-Authorization-for-Genetic-Testing/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 1/9/2025 | [**Availity, Concert Partner to Digitize and Automate Prior Authorization for Genetic Testing**](http://www.businesswire.com/news/home/20250109507578/en/Availity-Concert-Partner-to-Digitize-and-Automate-Prior-Authorization-for-Genetic-Testing/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 1/9/2025 | [**Availity, Concert Partner to Digitize and Automate Prior Authorization for Genetic Testing**](https://www.businesswire.com/news/home/20250109507578/en/Availity-Concert-Partner-to-Digitize-and-Automate-Prior-Authorization-for-Genetic-Testing/) | [[Business Wire]] | | 12/18/2024 | [**Overwhelming Confusion Around Prior Authorizations and Pricing Information Points to Need for Streamlined Solutions**](https://medtechintelligence.com/news_article/overwhelming-confusion-around-prior-authorizations-and-pricing-information-points-to-need-for-streamlined-solutions/) | [[MedTech Intelligence]] | | 12/18/2024 | [**Healthcare AI News 12/18/24**](https://histalk2.com/2024/12/18/healthcare-ai-news-12-18-24/) | [[HISTalk]] | | 12/17/2024 | [**Payer Practices are Top Health System RCM Stressors. Here's What to Do - HealthLeaders**](https://www.healthleadersmedia.com/revenue-cycle/payer-practices-are-top-health-system-rcm-stressors-heres-what-do) | [[HealthLeaders Media]] | | 12/14/2024 | [**ICYMI: Highlights From COA 2024**](https://www.ajmc.com/view/icymi-highlights-from-coa-2024) | [[AJMC]] | | 12/11/2024 | [**Meanwhile at HLTH2024: Other Interesting and Important Stories - Healthcare IT Today**](https://www.healthcareittoday.com/2024/12/11/meanwhile-at-hlth2024-other-interesting-and-important-stories/) | [[Healthcare IT Today]] | | 10/17/2024 | [**Healthcare Payer Services Business Research Report 2023-2024 & 2030 - Growth in Telehealth and Virtual Care Services Expands the Scope of Payer Services - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20241017425707/en/Healthcare-Payer-Services-Business-Research-Report-2023-2024-2030---Growth-in-Telehealth-and-Virtual-Care-Services-Expands-the-Scope-of-Payer-Services---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 9/26/2024 | [**Health IT Business News - September 26, 2024**](https://www.healthitanswers.net/health-it-business-news-september-26-2024/) | [[Health IT Answers]] | | 9/5/2024 | [**The biggest threat in health IT and RCM - Becker's Hospital Review**](https://www.beckershospitalreview.com/hit-speaker-series-q-a/the-biggest-threat-in-health-it-and-rcm.html) | [[Beckers Hospital Review]] | | 8/29/2024 | [**Healthcare Finance Trends for 2024: An Updated Look - HealthLeaders Media**](https://www.healthleadersmedia.com/cfo/healthcare-finance-trends-2024-updated-look) | [[HealthLeaders Media]] | | 8/26/2024 | [**Healthcare Finance Trends for 2024: An Updated Look - Becker's Hospital Review**](https://www.beckershospitalreview.com/healthcare-finance-trends-for-2024-an-updated-look.html) | [[Beckers Hospital Review]] | | 8/19/2024 | [**The Future of the Payer Industry: Join Fierce Healthcare Editors this Fall**](https://www.fiercehealthcare.com/sponsored/future-payer-industry-join-fierce-healthcare-editors-fall?itm_source=parsely-api) | [[FierceHealthcare]] | | 8/8/2024 | [**The Future of the Payer Industry: Join Fierce Healthcare Editors this Fall**](https://www.fiercehealthcare.com/sponsored/future-payer-industry-join-fierce-healthcare-editors-fall) | [[FierceHealthcare]] | | 7/10/2024 | [**HHS Proposes HTI-2 Rule to Enhance Healthcare Data Sharing and Interoperability**](https://hitconsultant.net/2024/07/10/hhs-proposes-hti-2-rule-to-enhance-healthcare-data-sharing-and-interoperability/) | [[HIT Consultant]] | | 10/12/2022 | [**Regence, MultiCare team on FHIR-enabled prior authorization**](https://www.fiercehealthcare.com/payers/regence-multicare-team-fhir-enabled-prior-authorization) | [[FierceHealthcare]] | ## Topic Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **Availity**: The largest real-time health information network in the U.S., offering intelligent authorization solutions to streamline prior authorization processes. - **Surescripts**: Collaborating with Cleveland Clinic and OptumRx to streamline the prior authorization process. - **Anterior**: A clinician-built AI company focused on enhancing healthcare administration and reducing administrative burdens, particularly in prior authorization processes. - **Careviso**: A healthcare technology leader focused on improving patient access and financial transparency in prior authorizations through strategic alliances and technology solutions. - **Cigna**: An insurer that has removed prior authorization requirements for 25% of medical services, impacting over 600 codes. - **Valer**: A company specializing in automating prior authorization processes to reduce staffing burdens for healthcare organizations. - **Clearwave**: Partnered with Valer to enhance patient intake experiences by automating prior authorizations. - **Sunknowledge Services Inc.**: A leader in prior authorization services, known for a 99% approval rate and reducing turnaround times by 30-40% through efficient, AI-driven solutions. - **Agadia**: A leader in utilization management solutions, known for its PromptPA portal that enhances efficiency in the prior authorization process. - **Cohere Health**: Partnered with MCG Health to improve the prior authorization process through integrated clinical intelligence. - **Clearway Health**: A healthcare organization partnering with Saint Peter's Healthcare System to enhance patient access to specialty medications and streamline prior authorization. - **American Medical Association (AMA)**: An organization advocating for reforms in prior authorization processes to alleviate administrative burdens on physicians. - **Itiliti Health**: Partnered with VirtualHealth to develop a solution for integrated care management and prior authorization. - **Thoughtful AI**: A company that has developed specialized AI agents to automate healthcare revenue cycle management tasks, including prior authorizations. - **Concert**: A company collaborating with Availity to streamline prior authorization processes for genetic testing. ### Partnerships and Collaborations - **Surescripts, Cleveland Clinic, and OptumRx**: Working together to significantly reduce the time required for prior authorization approvals. - **MetroHealth and Cognizant**: Collaborated to implement an automated solution that reduced prior authorization denials by 30%. - **Cohere Health and MCG Health**: Integrating clinical intelligence to enhance the prior authorization process for healthcare providers. - **Availity and Concert**: This partnership focuses on automating and digitizing prior authorization and payment processes for genetic tests, aiming to reduce administrative burdens on clinicians. - **Clearway Health and Saint Peter's Healthcare System**: A strategic partnership to establish a specialty pharmacy aimed at improving patient access to medications and addressing prior authorization challenges. - **Valer and Clearwave**: This partnership focuses on automating prior authorizations to improve patient intake and reduce administrative burdens. - **Mesh Health Solutions and KONZA National Network**: Collaborating to improve the prior authorization process for healthcare payers and providers, aligning with recent CMS regulations. - **WNS-HealthHelp and Availity**: A collaboration to integrate AI-driven clinical guidelines into Availity's utilization management solution, enhancing the prior authorization process. - **Blue Shield of California and Salesforce**: Announced a partnership aimed at streamlining the prior authorization process for healthcare services. - **VirtualHealth and Itiliti Health**: Collaborated to launch the HELIOS + Itiliti Health platform to enhance compliance with prior authorization regulations. - **Arrive Health and Amazon Web Services**: Developed the arrive ACCELERATE solution to enhance the prior authorization process using generative AI. - **IBM Watson Health and MedyMatch**: A partnership to integrate AI-based clinical decision support for detecting intracranial bleeding, which may impact prior authorization processes. - **Careviso and XiFin**: This strategic alliance aims to enhance operational efficiencies for diagnostic laboratories by integrating prior authorization services and revenue cycle management solutions. - **Anterior and NEA**: NEA's investment in Anterior aims to enhance healthcare administration efficiency. ### Innovations, Trends, and Initiatives - **Touchless Prior Authorization**: Surescripts' technology that automates manual workflows for medication prior authorizations, significantly reducing administrative burdens and expediting patient treatment initiation. - **Legislative Changes**: The reintroduction of the 'Improving Seniors' Timely Access to Care Act' aims to modernize prior authorization within Medicare Advantage plans. - **AI in Prior Authorization**: Innovations in AI are being leveraged to automate the prior authorization process, significantly reducing turnaround times and administrative burdens. - **Patient Communication Improvements**: Careviso's survey highlights the need for better communication regarding prior authorizations, with a focus on enhancing transparency and patient access. - **Real-Time Clinical Data Integration**: Promoted as a solution to streamline prior authorization processes and improve patient outcomes. - **Generative AI**: Leveraged by companies like Anterior to streamline prior authorization processes and reduce administrative burdens. - **AI Agents by Thoughtful AI**: Includes PAULA for Prior Authorizations, which automates tasks and significantly reduces operational costs and claim denials. - **PromptPA Portal**: Agadia's portal connects healthcare organizations to a network of health plans, streamlining prior authorizations for nearly 100 million lives. - **Generative AI in Medication Access**: Arrive Health's new solution that utilizes generative AI to enhance the prior authorization process and improve patient outcomes. - **Intelligent Authorization Solutions**: Availity is showcasing its API-powered intelligent authorization solution at HLTH 2024, aimed at improving healthcare interactions. - **Humata Health's Touchless Process**: The implementation of a fully automated prior authorization process that enhances operational efficiency and reduces human intervention. - **AI-Driven Solutions**: Sunknowledge and Salesforce are leveraging AI to automate and streamline prior authorization processes, reducing administrative burdens and improving efficiency. - **HELIOS + Itiliti Health Platform**: Integrates care management and prior authorization capabilities, ensuring compliance with evolving regulations. - **AI in Revenue Cycle Management**: AI is being integrated into RCM to address prior authorization issues, improve efficiency, and enhance patient care. - **Generative AI Applications**: Startups like House Rx are using generative AI to expedite prior authorization for specialty medications, achieving high approval rates. - **Health Data, Technology, and Interoperability (HTI-2) rule**: A proposed regulation aimed at standardizing electronic prior authorization processes and improving e-prescribing. - **HITRUST Certification**: Valer achieved HITRUST r2 Certification for its prior authorization management platform, demonstrating high standards of information security. - **AI and Automation in Revenue Cycle Management**: Healthcare executives are investing in AI and automation technologies to improve efficiency and address rising denial rates. - **BanjoConnect**: A suite of products that enhances communication between providers and payers, focusing on timely access to care. ### Challenges and Concerns - **Prior Authorization Delays**: 90% of healthcare providers report care delays due to inefficiencies in the prior authorization process, leading to unnecessary hospitalizations. - **Administrative Burden**: Prior authorization is a major administrative burden causing inefficiencies for both providers and patients, leading to treatment delays and increased clinician burnout. - **Administrative Burdens**: Prior authorization processes create significant delays in patient care, with over 90% of physicians reporting negative impacts on patient outcomes. - **Inconsistent Payer Requirements**: Specialty providers struggle with inconsistent payer requirements, complicating the prior authorization process. - **Regulatory Compliance**: Healthcare organizations must navigate complex compliance requirements, which can hinder the efficiency of prior authorization processes. - **Denial Rates**: Reports indicate rising denial rates for prior authorization requests, with significant financial implications for healthcare providers. - **Provider-Payer Disconnect**: The widening gap between providers and payers exacerbates administrative burdens and complicates the prior authorization process. - **Claims Denials**: Healthcare providers are ceasing to accept Medicare Advantage reimbursements due to rampant claims denials linked to prior authorization issues. - **Regulatory Compliance and Interoperability**: Challenges in regulatory compliance and data interoperability hinder the adoption of automation in prior authorization processes. - **AI Misuse in Care Denials**: Concerns over the potential misuse of AI in the prior authorization process, leading to increased denials and complications in patient care. - **Communication Gaps**: Over 80% of patients experience confusion regarding prior authorizations, highlighting significant communication gaps between healthcare providers and insurance companies. - **AI Decision-Making Risks**: The AMA raises concerns about unregulated AI in health insurance leading to increased prior authorization denials, emphasizing the need for human oversight. - **Rising Denial Rates**: Health systems are facing increased denial rates from payers, particularly in Medicare Advantage, complicating revenue cycle management. - **Inconsistent Denial Codes**: Inconsistent denial codes and sporadic updates from payers complicate the appeals process for healthcare providers. - **Senate Report on Insurers**: Criticizes UnitedHealthcare, Humana, and CVS for prioritizing profits over patient care through AI-driven prior authorization denials. - **Regulatory Scrutiny**: The federal government is examining Medicare Advantage plans, prompting health systems to reconsider their participation due to increased denials. - **Staffing Shortages**: Revenue cycle workforce shortages are exacerbating operational inefficiencies, prompting healthcare organizations to seek automation solutions. ## Related Topics [[Prior Authorization]]