Beyond the Checkbox: Better Prior Authorization Workflows
Michael Snow, PharmD
What if I told you that the healthcare system spends approximately $1.3 billion annually on prior authorization administrative costs alone, with physicians and their staff dedicating 13 hours per week to completing nearly 40 PA requests per physician, while much of that time is spent hunting for information that’s already sitting right there in the patient’s chart? As someone who spent years processing PAs and training other pharmacists to navigate these labyrinthine workflows, I can tell you that our current system is like trying to assemble IKEA furniture while someone randomly hides half the screws – technically possible, but unnecessarily painful for everyone involved.
The traditional PA process treats clinical documentation like a treasure hunt. Staff members scan through pages of medical records, looking for specific checkbox items: diagnosis codes, previous medication trials, lab values, and treatment durations. But here’s the problem – clinical care doesn’t happen in neat little boxes. A patient’s story unfolds across multiple visits, with relevant information scattered throughout progress notes, lab reports, and specialist consultations. When we focus only on extracting specific data points, we miss the bigger picture that often contains the most compelling evidence for treatment approval. It’s like reading only the chapter titles of a book and expecting to understand the plot.
This is where artificial intelligence transforms the game entirely. Modern AI systems can process entire medical documents comprehensively, understanding context and relationships between different pieces of information that human reviewers might miss or take hours to connect. Instead of just flagging that a patient tried metformin (checkbox: ✓), AI can identify that they experienced significant gastrointestinal side effects that led to discontinuation, tried lifestyle modifications for six months with minimal success, and have a family history of diabetes complications – all factors that paint a complete picture of medical necessity. Technology is not meant to replace clinical expertise; it actually amplifies it by ensuring that experienced pharmacists and medical professionals have all the relevant information organized and accessible when making coverage decisions.
The most exciting part? This isn’t about replacing the human element in healthcare – it’s about freeing up skilled professionals to do what they do best. When AI handles the heavy lifting of document review and information synthesis, pharmacists and doctors can focus on complex clinical decision-making, patient safety considerations, and building relationships with patients. The result is faster approvals for appropriate cases, better outcomes for patients, and less burnout for everyone involved in the process. Healthcare should be about healing, not paperwork marathons.
Ready to move beyond the checkbox mentality and transform your PA workflows? Learn how Epidaurus Health’s AI-powered solutions can help your organization process prior authorizations more efficiently and effectively. Visit us at epidaurus.health to discover how we’re helping healthcare organizations focus on what matters most – patient care.