While prior authorization is meant to promote appropriate and cost-effective care, it often creates delays and adds strain to practice workflows. By embedding a dedicated clinical pharmacy team, practices can ease this administrative burden, which boosts staff satisfaction and allows providers to spend more time where it matters most.
What is Prior Authorization?
Prior authorization means that certain medical services or prescriptions be approved by a health plan before they are provided. Previously in traditional Medicare, prior authorization was limited. That began to change with the introduction of Medicare Advantage plans. Today, most prior authorization requirements in Medicare come through Medicare Advantage. A 2022 survey by the American Medical Association (AMA) found that 93% of physicians reported care delays due to prior authorization.
Implications for Healthcare Providers
Prior authorizations (PAs) play a crucial role in ensuring patients receive safe, evidence-based, cost-effective care. By requiring clinical review before certain medications are approved, PAs reduce unnecessary interventions, minimize duplication of services, and promote adherence to guidelines. This process protects patients from unsafe or ineffective treatments while helping ensure healthcare resources are used responsibly.
Failure to secure prior authorization can result in denied claims, postponed care, and increased administrative workload. Beyond financial implications, these disruptions may negatively affect patient satisfaction and clinical outcomes. In value-based care settings, such delays may hinder the delivery of coordinated, preventive care and ultimately impact quality performance metrics.
Reducing PA Burden with Pharmacy Support
To address the challenges of prior authorization, CHESS partners with practices to embed a dedicated clinical pharmacy team. These pharmacists provide direct support by managing authorizations, finding cost-effective formulary options, and optimizing medications. Their involvement eases the administrative burden on providers and staff, boosting morale and freeing up time for patient care.
This approach speeds up prior authorization approvals, giving patients quicker access to the medications they need. By reducing delays, the partnership not only improves individual outcomes but also advances broader population health goals, turning an administrative hurdle into an opportunity for better care.
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