A practice that is losing time to prior authorizations.

What the situation looks like

Prior authorization is a queue that nobody owns. Requests are assembled by whoever has a free moment, submitted through a mix of payer portals, fax and phone, and then checked by hand until something comes back. Denials arrive without a clear reason and get resubmitted with the same information. In many practices the person doing the most of this is a clinician, because the clinician is the one who can answer the payer's questions.

The cost is not only the hours. Procedures are scheduled and then moved because the authorization did not arrive. Patients call to ask. The billing lead cannot tell anyone where a request is without opening three portals. The queue is longer at the end of every week than it was at the start.

What a practice usually tries

The first attempt is usually to hire someone. A new coordinator takes over the queue, learns the payers, and is competent within a few months, at which point the queue is manageable until they leave. The second attempt is usually a software product that promises to automate the whole thing and then needs the same coordinator to feed it and check it.

Both attempts fail for the same reason. The work has two kinds of steps in it. Some are rule-based and repetitive: assembling the request from the chart, submitting it to the right payer in the right format, checking the status, flagging the response. Some need a person: reading a denial, deciding what the resubmission needs, calling the payer, asking the clinician for what is missing. A person alone drowns in the first kind. Software alone stalls on the second kind. Each vendor sells one half.

How the four handle it together

The Medical Engineers automates the rule-based steps. Requests are assembled from the EMR, submitted to each payer in the way that payer accepts, and their status is checked automatically. Every response, every denial and every request that needs a person is flagged into one queue with the reason attached.

The Medical Staffers places a remote revenue cycle specialist to work that queue. The specialist reads the denials, prepares the resubmissions, calls the payers and asks the clinician only for what the clinician alone can supply. The specialist works inside the practice's EMR, is interviewed by the practice and is trained on the automation before starting.

The two are set up together, which is the point. The specialist and the software share one queue instead of two, so nothing is submitted twice and nothing sits in a portal that nobody checks. The clinician stops doing either job and answers a short list of questions instead. If the practice's website or patient material needs to explain the authorization process to patients, The Marketing Surgeon writes that page and Medical AI Videos can turn the same wording into a short video for the booking email.