Thirteen hours a week on prior auth
The clinical decision takes minutes. The paperwork around it takes a part-time employee.
Read this first
3 things that decide this
- 01Practices handle roughly 40 prior authorization requests per physician per week, and Rivet Health puts the staff cost near 13 hours weekly.
- 02Athenahealth's own analysis calls prior auth one of the most manual workflows left in medicine, still dominated by fax and phone.
- 03The clinical judgment in a prior auth is small. The document assembly, status checking, and resubmission around it is the part software can take.
A decision that takes minutes, wrapped in a week of chasing
A physician orders an MRI. Whether the payer will cover it is usually knowable from the chart in a few minutes. What follows instead is a workflow from 1998. Someone at the front desk finds the payer's form, pulls chart notes, faxes a packet, and then calls to ask whether the fax arrived. Rivet Health's analysis of the burden counts about 40 of these requests per physician every week.
Multiply that across a three-physician practice and prior auth quietly becomes a full workday of staff time, every week, spent moving documents rather than treating anyone. More than 90 percent of physicians in athenahealth's reporting say the process delays care.
Why prior auth resists the tools practices already own
The EHR holds the chart. The payer portal holds the form. The fax machine holds the proof of submission. No one of those systems can see the other two, so a person becomes the integration layer. That person re-keys demographics, copies clinical notes into payer forms, and keeps a spreadsheet of which requests are pending.
Practice management vendors sell pieces of the fix, but every payer's rules differ and the practice's own workflow differs again. The result is that the human glue stays, and it stays expensive.
- 01Payer requirements vary enough that one template never fits all requests.
- 02Status checking is polling by phone, which no staffer can do continuously.
- 03Denials for missing documents restart the whole loop from zero.
Automate the chasing, keep the clinical call human
The workable split is clean. Software assembles the packet from the chart, fills the payer form, submits it, and checks status until something changes. A person reviews the packet before it goes out and handles the genuine clinical questions. The 13 hours shrinks toward the minutes of judgment that were always the real work.
This is a document pipeline with a verification gate, and that shape is well proven outside medicine. Shift Link, a workforce compliance platform we built, validates right-to-work documents before a worker can be dispatched. The same gate pattern applies to a prior auth packet: nothing leaves incomplete, and a human signs off where it matters.
Document gates that hold
What practice administrators ask
01Is prior auth automation allowed under HIPAA?+
Yes, with the standard safeguards: a business associate agreement, access controls, and audit logging. The automation handles protected health information the same way your EHR vendors already do. What HIPAA rules out is casual tooling with no agreement behind it.
02Do payers accept automated submissions?+
Payers accept submissions through their own portals and fax lines regardless of what produced them. The packet looks the same. Several large payers now run electronic prior auth programs that make machine submission the preferred path.
03What stays human in this workflow?+
Clinical judgment and the final review. A reviewer sees each packet before submission, and any request needing peer-to-peer discussion routes to the physician. The automation removes assembly and chasing, not accountability.
