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Prior Authorization Turnaround & Approval Uplift
Centralized intake, payer-specific checklists, and escalation macros cut TAT and raised approvals.
Context
- Decentralized prior auth across clinics created inconsistent criteria checks and poor visibility.
- Frequent resubmissions and last-minute escalations impacted schedules and patient experience.
- No single queue or coverage model; handoffs delayed callbacks.
Approach
- Centralized prior auth desk with coverage grid by interval aligned to booking patterns.
- Payer-specific checklists, clinical criteria prompts, and attachment rules embedded in the workflow.
- Escalation matrix with time-boxed callbacks and macro templates for payer follow-ups.
- Status and jeopardy views for high-risk cases (near DOS or expiring).
- Dashboards for TAT, approval rate, resubmission rate, and jeopardy backlog.
Measured Results
- Median authorization TAT −32%.
- Approval rate +7.4 pts through better criteria evidence.
- Day-of-surgery cancels −41%.
- Resubmissions −24% with clearer initial packets.
Lessons Learned
- Interval staffing beats headcount averages when demand is spiky.
- Checklists must mirror payer criteria, not generic steps.
- Jeopardy queues need owners and clocks; make risk visible.
- Macros reduce variance and speed payer callbacks.
Faster approvals, fewer surprises
We’ll implement criteria checklists, escalation macros, and jeopardy views.
