Operational Tactics to Manage Prior Authorizations in Health-System Organizations (147H)

Prior authorizations for medical care were established in the 1960s when increased scrutiny on healthcare service utilizations began with the creation of Medicare and Medicaid governmental programs. This cost-containment tool has expanded to all parts of healthcare and has morphed from a well-intended effort to curb rising costs of care to a barrier to timely and appropriate care for patients. While prior authorization practices have received more recent attention at various state legislative forums, there are still significant areas for improvement.

The Institute of Medicine's Quadruple Aim is to enhance the patient's experience, improve population health, reduce healthcare costs and improve the work-life of healthcare providers. By adding attention to this currently required yet costly administrative burden to front-line clinicians who otherwise would be providing value-added patient care, healthcare executives will not only positively improve their staff job satisfaction but also see an improvement in their financial return on investments. This session will provide a background and timeline for improvements in the prior authorization process at a free-standing pediatric academic medical institution; describe lessons learned from this process improvement for attendees to use at their respective organizations; share provider experiences with how current prior authorization processes are a contributor to provider dissatisfaction and burnout; create a forum in which participants share their own experiences with prior authorization to foster best-practice sharing; and provide resources and tools that attendees can use to implement and refine their organizational processes. The use of the forum-sharing format as well as two methods implementing tactics to addressing prior authorizations barriers across a health-system will provide tangible takeaway tools to aid institutions in pursuit of the IOM Quadruple Aim.