At A Glance
Automated prior authorization solutions streamline workflows, simplify management across payer systems and offer advanced features to reduce manual effort — helping providers minimize denials and improve overall efficiency.
Key takeaways:
- Prior authorization is a process used by providers and payers to determine if a patient’s insurer will cover a specific treatment before service.
- Manual prior authorization systems are common, but labor intensive, expensive and unable to keep up with evolving payer rules and compliance needs.
- Organizations can leverage automated prior authorization software, such as Experian Health’s Authorizations, to boost efficiency and improve cash flow.
Manual prior authorization processes are still the norm in healthcare, despite being costly and inefficient. The Council for Affordable Quality Healthcare (CAQH) predicts that providers who make the transition from manual to automated prior authorization software could see significant cost savings and a reduced administrative burden on staff.
Yet, only 31% of providers have made the switch.
Here’s a closer look at how providers can leverage automated prior authorization software to speed up the authorization process and maximize reimbursements.
What is a prior authorization and why is it required?
A prior authorization determines if a patient’s insurance plan will pay for a specific treatment. Requirements vary widely by payer, the type of patient insurance policy and other factors.
When prior authorization is required, the provider submits a prior authorization request to the payer and includes a rationale for the proposed services. Then, the payer approves or denies the request based on certain criteria, like medical necessity and payer policies.
Providers that offer services without prior authorization risk higher claim denial rates and non-reimbursement from payers. This can result in potential cash flow issues–leaving billing teams stuck chasing patient collections to keep revenue cycles on track.
How long does a prior authorization typically take?
How long a prior authorization takes depends on several factors, like practice size and whether staff is using manual processes or automated prior authorization software. Individual payer rules and decision timelines also affect turnaround times.
On average, providers spend about 13 hours a week processing prior authorizations, according to an American Medical Association survey. The data also shows that most practices complete close to 40 prior authorizations per week, per physician.
How do incomplete or missing prior authorizations lead to claim denials?
Incomplete or missing prior authorizations can ultimately lead to claim denials. Prior authorizations help providers and payers understand what a patient’s insurance covers–up front. However, they also play a critical role when submitting cleaner claims.
According to Experian Health’s 2025 State of Claims report, issues with authorizations are to blame for 35% of denied claims. Additionally, claims for services not covered trigger approximately one-quarter of denials.
To reduce denial rates and maximize reimbursements, providers must prioritize obtaining prior approvals and submitting claims with accurate and complete prior authorization documentation.
What are the challenges of manual prior authorizations?
Despite access to automated prior authorization tools, manual prior authorization processes are still commonly used by many providers. Challenges of manual prior authorizations include:
- Inefficient workflows: Coping with complicated prior authorization requirements and disjointed communication systems often strains manual systems. When multiple staff are involved, they may have different pieces of information from payer websites (or over the phone) and lack a way to communicate shared knowledge efficiently. This can result in workflow inefficiencies that snowball rapidly.
- Heavy administrative burden: American Medical Association data shows prior authorization requires about two days a week of administrative time, and 40% of providers have staff who exclusively work on them. Nearly 90% of physicians also report prior authorizations increase physician burnout.
- Changing payer policies: Payer policies are constantly evolving and updates are often unannounced. As a result, providers may submit inaccurate prior authorization requests or requests that are based on outdated rules. This can lead to instant rejection, time-consuming corrections and resubmissions and delayed reimbursements.
What’s the business case for prior authorization software?
When making the business case for automated prior authorization software, consider these key areas:
1. Faster workflows
Automated prior authorization solutions increase overall efficiency – initiating more requests in less time. This allows staff to focus on other priorities instead of chasing down documentation and reworking denials. Automated prior authorization tools also take charge of monitoring and managing requests – reducing the need for manual follow-up.
2. Easier authorizations management
With automated prior authorizations, staff no longer need to log into multiple payer portals and cross-reference rules and requests by hand. Communication is streamlined, allowing staff to quickly check the status of prior authorization requests. Prior authorization submissions are based on real-time payer rules and contain accurate and complete information–reducing the likelihood of denials and the need for resubmissions.
3. Enhanced features
Prior authorization software typically includes features and services that go far beyond manual systems. For example, Experian Health’s Authorizations offers an add-on post-back service that seamlessly integrates with hospital information and patient management systems–making it easy to confirm authorization status, number and validity dates and flag any inconsistencies. Automated prior authorization tools are also typically designed to spot potential discrepancies and prevent denials.
What features should providers look for in a prior authorization automation platform?
When making the transition from manual to automated prior authorization, look for a solution that offers a wide range of features to speed up the prior authorization process. For example, Experian Health’s Authorizations tool offers healthcare providers the following key features:
- Real-time knowledgebase with access to up-to-date prior authorization requirements and criteria in the National Payer Rulesets.
- Submissions support to remove guesswork and direct users to the correct payer portal based on procedure.
- Automated inquiries to automate the prior authorization payer inquiry process.
- Enhanced workflow with dynamic work queues that display status and guide users through next steps.
- Postback that allows users to easily send authorization status, number and validity dates to health information systems (HIS) and practice management systems (PMS).
- Image storage capable of receiving and securely storing payer responses in an integrated document imaging system.
- Reconciliation that provides insights into authorization variations and helps resolve them, so staff can take proactive steps to prevent denials and appeals.
The bottom line: What can healthcare leaders expect for the future of prior authorizations in 2026?
Prior authorizations are in a state of constant flux and are complicated to manage. However, providers who implement automated prior authorization software will be better equipped to keep pace.
Alicia Pickett, Senior Product Manager at Experian Health, notes that making the switch to automated prior authorization software is a big change, but the results can be transformational. Automating prior authorizations helps providers work more efficiently, create consistency and deliver higher-quality patient care. She explains:
“When providers use manual processes, leaders and managers aren’t able to gather insights because there’s nothing to tie metrics to. In addition to creating more efficient workflows, automated tools, like Experian Health’s Authorizations solution, provide metrics organizations can use to evaluate and plan.”
Automating prior authorizations also helps providers comply with the CMS final rule on prior authorizations, which is set to take effect in 2026. Picket believes this may be the biggest motivator for change in prior authorizations, along with several state mandates that require more transparency and quicker turnaround times.
“Because of the CMS mandate, and because of the options that are available with expanding technology, we expect to see improvement in physician satisfaction and reduction in delays that impact patient care. More data will be available on what requires an authorization, or on where an authorization stands,” Pickett explained.
See how Experian Health’s Authorizations is helping healthcare organizations streamline, simplify and speed up the prior authorization process.
