Prior authorization administration consumes an estimated $35 billion a year across U.S. healthcare, and that figure excludes the cost of delays, denials and abandoned treatment. The abandonment is the part that compounds. Seventy-eight percent of physicians say prior authorization leads patients to walk away from treatment they were prescribed.
Six health systems moved that work off their clinical teams: Cone Health, Ochsner Health, St. Luke’s Health System, MetroHealth, Yale New Haven Health and University Health, Kansas City.
The work they moved had migrated into clinics as unbilled shadow labor. A medical assistant spending 30 minutes on a single authorization between patient visits. A provider finishing documentation at night. A physician pulled into a peer-to-peer review to argue medical necessity with an insurer. None of it is reimbursed, and all of it displaces patient care.
Among the results:
- Ochsner Health cut appeal drafting from more than 30 minutes to 7.2 minutes
- University Health, Kansas City reclaimed about 400 nursing hours per week
- MetroHealth secured $50 million in copay assistance for its patients and lifted specialty fill capture above 85%
This report breaks down what each system did and what it produced.
Learnings include:
- How centralizing prior authorization returns clinical hours to patient care
- What cleaner submissions do to first-pass approval rates
- Where dispenses leak out of the system and which leaks are controllable
- How leaders turned patient capture into a number they manage