Taking Responsibility for Authorization Delays
Health systems must take ownership of the broken prior authorization process rather than placing blame solely on insurance companies, according to Jeff Balser, CEO of Vanderbilt University Medical Center. Speaking at Forbes’ Healthcare Summit in New York City, Balser challenged the conventional narrative about authorization delays.
“A lot of the work and time and delays with prior authorization are actually on our end,” Balser declared during the panel discussion. His candid assessment highlights a critical issue often overlooked in healthcare administration.
Provider-Side Improvements
Balser emphasized that healthcare providers can initiate the prior authorization process immediately when patients schedule appointments. This proactive approach significantly reduces wait times and prevents treatment delays. Many authorization denials don’t occur because services are medically inappropriate—they happen because providers submit incomplete documentation or fail to include essential information required by payers.
To address these challenges, Balser stressed that health systems must invest in better workflows and establish centralized authorization teams. This structural change prevents individual physicians from shouldering the administrative burden alone, allowing them to focus on patient care rather than paperwork.
AI Solutions Streamline Authorization Workflows
Artificial intelligence represents a game-changing opportunity to revolutionize the prior authorization landscape. Vanderbilt University Medical Center is already implementing machine learning tools across its clinic network to identify precisely what information each payer requires for approval.
Autonomous Data Collection
“The information that the insurance company needs is all in the health record,” Balser explained. Vanderbilt is developing AI processes that can autonomously gather required information from electronic health records for prior authorization requests. Clinicians would simply review and approve the compiled data before submission—eliminating hours of manual documentation work.
This automation doesn’t just save time; it dramatically improves accuracy by ensuring all necessary information is included in initial submissions, reducing denial rates and resubmission cycles.
Standardization and Gold-Carding Programs
While technology offers powerful solutions, Balser emphasized that partnerships with insurance payers remain essential for meaningful reform. Vanderbilt is actively collaborating with payers on two critical initiatives: standardization and gold-carding programs.
Creating Consistency Across Plans
The health system works with multiple payers to standardize prior authorization requirements across different insurance plans. This consistency eliminates confusion about varying requirements and reduces administrative complexity for providers navigating multiple payer policies.
Rewarding Quality Performance
Gold-carding represents an innovative approach to authorization efficiency. This policy exempts clinicians from prior authorization requirements in clinical areas where their approval rates consistently remain extremely high. By removing thousands of unnecessary reviews for proven high-quality providers, gold-carding accelerates patient access to care while maintaining appropriate oversight.
Payer-Provider Collaboration Drives Innovation
Steve Nelson, executive vice president at CVS Health and president of Aetna, joined Balser on the panel and strongly advocated for payer-provider partnerships. Drawing from his leadership experience in both sectors, Nelson directly challenged industry assumptions.
“There’s a myth out there that payers and providers cannot work together. I’ve led organizations in both spaces, and I’m telling you that it’s not true. We do not despise each other,” Nelson stated emphatically.
His perspective underscores that collaboration between these stakeholders isn’t merely possible—it’s absolutely essential for transforming healthcare delivery and improving patient outcomes.
Bundled Authorizations Simplify Patient Care
Aetna is pioneering new approaches to streamline the authorization process through care episode bundling. Rather than requiring separate authorizations for medications, procedures, and follow-up appointments, the payer now offers single prior authorizations for complete care episodes.
Episode-Based Authorization Examples
This bundled approach applies to various treatment scenarios, including:
- Complete IVF (in vitro fertilization) treatment cycles
- Comprehensive cancer care journeys from diagnosis through treatment
- Integrated musculoskeletal condition management programs
This episode-based model reduces administrative burden while ensuring patients receive coordinated, comprehensive care without authorization-related interruptions.
The Future of Prior Authorization
Nelson also highlighted Aetna’s commitment to modernizing data exchange infrastructure. The payer is replacing outdated, “archaic” data exchange methods with faster, more accurate networks. These technological improvements enable faster decision-making with improved accuracy, benefiting both providers and patients.
The convergence of provider accountability, artificial intelligence, standardization efforts, and improved payer-provider collaboration signals a promising future for prior authorization reform. As these initiatives mature, patients should experience fewer treatment delays and more efficient healthcare delivery.
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