A Business Case for Prior Authorization Automation in 2025
In 2024, many questions were raised about the current state of prior authorization processes. As delays, denials, appeals, and administrative costs soared, so did scrutiny around the use of AI to process claims and payer requirements, leading to adverse patient outcomes.
The push for greater insight into the lifecycle of a prior auth claim prompted overdue legislative action, including the finalized CMS rule tied to prior authorization to enhance transparency and data collection throughout the process. Separate from federal legislative action, local regulatory movements picked up steam, with nine states having passed comprehensive legislation focused on different areas of prior authorizations, including response times, data requirements, and even “gold carding.”
Industry reports, surveys, and research focused on the state of prior authorizations only paint part of the picture when determining where there is room for improvement. In this blog, we’ll walk through a few of the most important prior auth trends that came to light last year and how Valer can come into play to streamline the process for your organization in 2025.
Care Delays and Denials
One of the greatest opportunities in healthcare is to mitigate patient care delays and denials from inefficient prior auth processes. Delays negatively impact patient satisfaction and leakage, organizational revenue, staff utilization, and more. A report from the American Medical Association (AMA) found that 94% of physicians report delays in care due to prior auths—a staggering statistic.
Prior authorization denials are on the rise, especially for Medicare Advantage (MA) claims, due to the manual nature of the processes. Payers lack transparency and standardization around what treatments require prior auths, and providers spend hours manually inputting CPT codes and patient information into claims that may contain errors, leading to denials. Another industry report found that in just one year (between 2022-2023), care denials increased by more than 20% for commercial claims and 55% for MA claims. A significant factor driving this increase is the use of artificial intelligence tools that can lead to automatic denials due to inefficient review by a clinician or payer.
How Valer Helps:
Our automation technology focuses on streamlining and simplifying the submission and verification portion of the prior auth process. We leave the prior auth determination to the payers because of the costly impact on providers and patients when it’s done wrong. Valer is a trusted “magic button” for automating submissions, status checking, verification, reporting, and EHR synchronization. There aren’t many other solutions that can say the same. By automating these processes, we can save your staff time and help patients get the care they need faster.
Staff Burnout
Staff burnout is a disturbing trend affecting not only the quality of life for healthcare workers but also undermining patient care. A recent analysis from the World Health Organization found that since 2022, at least a quarter of healthcare workers have reported burnout symptoms. By spending around 12 hours per week on prior auths – checking status multiple times a day, communicating with payers, navigating changing requirements, etc. – staff feel the burden of manual processes.
How Valer Helps:
Instead of relying on administrative staff to manually enter data and submit prior authorization requests, Valer automates the entire process, ensuring that submissions are timely and accurate. For Valer clients like Oregon Health & Science University, utilizing the solution has led to a 45% reduction in total staff time required for submissions, allowing teams to focus on more critical tasks and reducing the likelihood of manual errors.
Changing Payer Requirements
A lack of standardization across the industry means an ongoing burden of cumbersome, confusing processes and changing rules for prior authorization. Providers use different workflows, while payers have the ability to update their requirements without giving advanced notice to healthcare organizations. This fragmented approach creates confusion and delays, especially when using manual workflows.
How Valer Helps:
With run-time changeability, Valer supports providers by keeping claims up-to-date regardless of when a change occurs. Our platform picks up on updated requirements, sending a notice to providers in real-time, allowing the team to update claims with correct or new information to ensure it is approved. This visibility limits the chances for denial and cuts down on care delays, improving revenue.
A True Prior Authorization Automation Partner for 2025
The healthcare industry faces growing challenges around prior authorization, with inefficiencies leading to care delays, rising denial rates, and significant administrative burdens. At the same time, regulatory advancements and technology innovation are signaling a turning point for the industry. Now’s the time to invest in a prior authorization automation solution like Valer. It’s no longer a “nice to have,” it’s a strategic imperative for large healthcare practices looking to make a meaningful change in 2025.
Let this be the year your organization redefines the prior authorization process and sees the difference true submission and verification automation can make. Contact us today to get started.
