Breaking the Bottleneck: How Healthcare Payers Are Streamlining Prior Authorizations

Breaking the Bottleneck: How Healthcare Payers Are Streamlining Prior Authorizations

Shifting attitudes around prior authorizations are a win for patients, providers, and payers. Learn how Salesforce is helping in this remarkable transformation.

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Prior authorizations are a fixture of our healthcare system, helping ensure that care and therapies are medically necessary and cost effective. But they have historically presented significant challenges for both members and healthcare providers, frequently leading to frustrating delays in care delivery and increased administrative burdens. Today, the landscape of utilization management in U.S. healthcare is evolving. Major insurance carriers and health plans are actively engaged in streamlining and accelerating the approval process. This represents a substantial advancement toward a patient-centric approach, leveraging technology and collaborative efforts to ensure timely access to essential treatments.

A new take on prior authorizations

The recent headlines from CNBC, AHIP, and others highlight a collective commitment to reform. By streamlining the prior authorization process, insurers aim to reduce administrative overhead and improve the overall member experience. This initiative is particularly impactful for patients requiring ongoing care or specialized procedures, where delays can have significant consequences.

At the heart of this transformation is the integration of advanced technology and strategic partnerships. For instance, a large, California-based health plan is collaborating with Salesforce to make prior authorizations as seamless as a credit card transaction. This vision underscores a future where approvals are swift and transparent, minimizing the current bottlenecks.

Technology platforms are leading the way in utilization management

Care management and utilization management solutions are playing a pivotal role in this evolution. Innovative partnerships with MCG, athenahealth, and Ellipsis Health are enhancing the efficiency of care coordination and ensuring that utilization reviews are data-driven and timely. These advancements are crucial for optimizing resource allocation while prioritizing patient needs.

In addition, the combined power of AI and CRM technologies is revolutionizing how prior authorizations are handled. The use of predictive, generative, and now agentic AI solutions, backed by real-time clearinghouse integrations with Availity and Infinitus.ai, is automating routine tasks and accelerating decision-making. Health Cloud's out-of-the-box capabilities combined with Data Cloud and MuleSoft APIs further enhance this process, providing a comprehensive and connected system for payers.

Payers are seeing the benefits of their new approach

Salesforce's commitment to interoperability and speeding time to treatment has enabled payers to realize tangible benefits from its utilization management (UM) solution. A Chicago-based health plan implemented and expanded in less than six months, turning its brittle prior authorization process into a fast, flexible platform that connects and improves all areas of payer operations, from its contact center to community engagement and from claims data for prior authorizations to automated workflows with improved data integrity and insights.

Another UM customer is providing physicians and their patients prior authorization answers in near-real time, bringing together 20+ disparate systems that exist today into one process that integrates with physicians' current workflow. This results in the plan's ability to:

• Support twice as many members
• Cut benefits processing time by 99.7%, or from 24 hours to 5 minutes
• Increase digital enrollment by 75%
• Decrease manually reviewed group enrollment by 50%
• Consolidate 13 care management data sources into 1

Finally, a New York-based health plan implemented UM to reduce costs, improve the provider experience, and deliver necessary, timely care to its members through automated, intelligence-driven flexible workflows for UM. Ultimately, it discovered that with Salesforce at the center of its operations, it was better able to adapt to changing market conditions, maintain regulatory compliance more easily, scale rapidly, and exceed its customers' expectations.

These success stories underscore the tangible benefits of a deeply unified platform that encompasses not only technological upgrades, but a collaborative ecosystem where payers, providers, and technology partners work in tandem to improve healthcare delivery. The move toward a more efficient prior authorization process is a win for everyone involved. Patients benefit from quicker access to care, providers can focus more on treatment and less on paperwork, and health plans can operate with greater efficiency and transparency. This paradigm shift marks a significant step forward in building a healthcare system that truly prioritizes patient wellbeing.

AI supported the writers and editors who created this article.

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Sarah has been a product marketer at Salesforce since 2018. In that time, she's covered Philanthropy Cloud, Net Zero Cloud, and most recently the Healthcare industry, with a focus on payers. Prior to her time at Salesforce, she marketed SaaS-based B2B enterprise solutions and spent more than a...Read More decade editing consumer technology magazines and websites.