WEDI: Tech limitations, lack of adoption and standards causing prior auth issues

The use of technology has made limited inroads in reducing the impact of prior authorization, even as requests for this documentation increases, according to a national group’s recent survey.

WEDI—the Workgroup for Electronic Interchange—says its research suggests that even the use of mandated standards have done little to curb in the impact the prior authorization requirements.

WEDI’s Prior Authorization Subgroup conducted the survey last August, and it shared the findings during testimony late last year before the National Committee on Vital and Health Statistics.

Results of the survey were also presented during a December briefing on Capitol Hill, where a panel of WEDI experts addressed policymakers and federal agencies to announce emerging automation trends that can reduce prior authorization challenges, lower costs and improve patient care.

The survey analyzed the current medical services prior authorization process, and WEDI executives say it will be used to develop guiding principles to support increased automation and standardization, in efforts to relieve physicians of documentation burdens.


“While the industry has made great progress, this survey shows how much more work there is to be done to clarify and standardize prior authorization workflows,” says Jay Eisenstock, chair of WEDI’s board of directors.

Findings from the WEDI survey show that perceptions of the burden imposed by prior authorizations are dimming. For example, 84 percent of responding providers said the number of medical services that require prior authorizations has increased; 55 percent of vendors report the number of medical services that require prior authorizations has increased; and 42 percent of payers acknowledge the number of medical services that require prior authorizations has increased.

While information technology could alleviate some of the prior authorization pressure, it’s not being fully utilized, and current approaches make it difficult to determine whether a prior authorization is required without initiating a request, the WEDI survey contends. For example, 62 percent of providers say they do not have a technology to evaluate whether a prior authorization is required without initiating a request; and, only 45 percent of vendors report having the technology in place to evaluate whether prior authorizations is required without initiating a request.

For now, the question is whether payers and regulators are ready to address the pain points of prior authorization, and Eisenstock believes that they are.

“You can’t attend a meeting without addressing prior authorization because the burnout rate is too high,” he contends. “We hear stories about patients being denied treatment” because of issues with prior authorization, “and that gets the attention of the government,” he explains.

WEDI’s presentations to congressional staffers on Capitol Hill on the need to find solutions to the burden of prior authorization requirements, while maintain the benefits of the information exchange it produces to help serve as an industry guardrail to control costs, which is what lawmakers wanted to hear, according to Eisenstock.

The dilemma is balancing rising costs for providers and enabling insurers to get the data documentation they need to ease burdens and make the prior authorizations process more efficient and standardized for both sides while easing physician burden. Plans will still need data documentation from providers so they can do their jobs, and providers will still want to be self-policing, he adds.

Some technology firms have been pitching their services, but if fixing prior authorization was easy, it would have been done by now, Eisenstock concludes. “Technology can help, but policy and process issues are at the heart of prior authorization.”