By Dr. Steve Kim, Valer Co-Founder and CEO
This is Part 6 of our 10-part series examining the deep, interconnected complexities that keep prior authorization broken. While many hospital and health systems hope new regulation (CMS-0057-F) and AI will improve processes, the real barriers to progress lie in systemic challenges that span technology, workforce, regulation, and operations. These barriers won’t be eliminated by regulation, payer pledges, or today’s AI solutions—but providers have more control than they might think. Throughout the series, we’ll break down the entire prior auth landscape and include practical recommendations that can make a difference.
Your patient access team has successfully navigated authorization requirements, submission portals, and provider-facility matching. Now comes what should be straightforward: gathering the clinical documentation that proves the patient needs the requested service.
Except staff must compile comprehensive clinical evidence without clear guidance on what will actually be deemed sufficient. Payers maintain proprietary medical necessity criteria that often aren’t transparently shared with providers, forcing clinical documentation into a trial-and-error system where staff hunt through electronic health records (EHR) hoping they’ve included the right information.
Challenge #1: Inconsistent and Opaque Payer Guidelines
While Medicare publishes National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), commercial payers often use proprietary medical necessity criteria like MCG Care Guidelines or develop their own internal requirements.
As a result, staff do not always have any way to know which specific diagnostic codes, lab values, prior treatment failures, or clinical findings the payer requires. Documentation becomes guesswork based on institutional memory. When denials cite insufficient documentation, staff finally learn what should have been included—but only retrospectively.
The problem extends to Medicare Advantage (MA) plans, where investigations have uncovered denials that conflict with published NCDs and LCDs, suggesting MA plans apply additional proprietary criteria beyond Medicare’s stated requirements.
The solution: Implement actionable guidance staff can use when compiling documentation. This becomes easier when aligning with a vendor like Valer that systematically maps payer criteria through analysis of approval and denial patterns.
Challenge #2: Fragmented Documentation Workflow
Clinical information lives scattered across EHR systems in different modules and formats. A single prior authorization might require staff to pull information from provider notes, imaging reports, lab results, medication lists, prior treatment documentation, specialist consultations, discharge summaries, and therapy notes.
Staff must manually navigate multiple screens, copy-paste information, and compile everything into formats that payer portals will accept. For complex cases requiring extensive clinical history, they may need to review months or years of records to document prior treatment failures or disease progression.
This manual process doesn’t just consume time—it creates real risk of missing critical information that wasn’t easily visible or whose relevance to undisclosed payer criteria wasn’t obvious.
The solution: Implement technology that integrates with EHR systems to automatically identify and extract relevant clinical information based on the specific service and payer requirements, presenting staff with pre-populated documentation they can review rather than building from scratch.
Challenge #3: Undertrained Staff Handling Complex Processes
Patient access teams responsible for compiling clinical documentation often lack medical training. They’re administrative staff expected to make judgment calls about which clinical information is relevant, sufficient, and appropriately contextualized for medical necessity determinations.
But these staff members often rely primarily on “tribal knowledge” about what works for different payers. When staff leave, their accumulated knowledge disappears with them. New hires start from scratch, repeating the same learning process.
The lack of medical training also creates risks that staff may not recognize the clinical significance of certain documentation elements, potentially missing crucial context that explains why standard treatments weren’t appropriate.
The solution: Develop standardized documentation protocols that codify institutional knowledge. Provide decision support tools that guide staff through requirements based on the specific service and payer, with clear explanations of why certain information matters.
Challenge #4: DaVinci FHIR Implementation Challenges
The Da Vinci FHIR Document Template and Rules (DTR) specification aims to streamline clinical documentation, with payers sharing structured questionnaires directly within the EHR. Now, in addition to documenting clinical encounters, providers must complete payer-specific questionnaires with decision trees that may require additional chart review or research. The complexity varies dramatically with some involving straightforward questions, and others requiring detailed clinical assessments or extensive treatment history review.
The Da Vinci DTR also assumes payers will create clear, reasonable questionnaires that focus on truly necessary information. If payers instead use this mechanism to request excessive documentation, that could create workflow disruptions rather than reduce the documentation burden.
The solution: As DTR implementations roll out, carefully evaluate whether they actually reduce total organizational burden or simply shift it to different roles. Establish clear protocols for who completes questionnaires and provide feedback to payers when questionnaires are unnecessarily complex.
Challenge #5: The Real-Time Adjudication Catch-22
America’s Health Insurance Plans (AHIP) has set a voluntary goal that by 2027, 80% of electronic prior authorization decisions will be answered in real time when providers supply complete information. But this framing obscures a fundamental challenge: providers can only supply “complete information” when they know what information is actually required.
When criteria are proprietary and undisclosed, achieving high rates of complete upfront submission is virtually impossible. Staff either over-document, consuming excessive time, or under-document, triggering denials or additional information requests.
The push toward real-time decisions risks becoming another way to shift blame to providers for “incomplete submissions” without acknowledging that incompleteness often stems from payers’ not clearly specifying requirements.
The solution: Use technology solutions that learn from approval and denial patterns to approximate what payers want, even when it’s not stated clearly.
Moving Beyond Guesswork
The clinical documentation challenge reveals a fundamental power imbalance in prior authorization. Payers hold proprietary criteria and can reject authorizations for failing to meet undisclosed standards, while providers frequently have to submit documentation more than once.
This isn’t about providers being unwilling to demonstrate medical necessity—it’s about being put in the tough position of having to do so without clear guidance on what evidence payers will accept. The resulting system wastes enormous resources while delaying patient care.
The path forward requires both advocacy for regulatory transparency and practical solutions that help providers navigate the current reality. While transparency slowly improves, technology that maps payer patterns, automates documentation compilation, and provides decision support can reduce the guesswork.
Next up in Part 7: How authorization status tracking becomes nearly impossible amidst incomplete information, requirements that change mid-process, and unclear communication about determination timelines—and what provider organizations can do to take more control.
Frequently Asked Questions About Prior Authorization Documentation
What are medical necessity criteria in prior authorization?
Medical necessity criteria are the clinical standards payers use to determine whether a requested service or treatment is appropriate and warranted. While Medicare publishes its criteria through NCDs and LCDs, most commercial payers use proprietary guidelines that aren’t always shared with providers, forcing healthcare organizations to guess what documentation will be deemed sufficient.
Why is clinical documentation for prior authorization so time-consuming?
Clinical documentation is time-consuming because information is scattered across different EHR modules, payers don’t clearly specify what they need, and staff must manually compile and format documentation for each submission. Without transparent guidelines, staff often over-document to avoid denials or spend significant time gathering additional information after initial denials.
How can providers improve their prior authorization documentation process?
Providers can implement technology that integrates with EHR systems to automatically extract relevant clinical information, develop standardized protocols that codify institutional knowledge, and work with partners that map payer approval patterns to understand undisclosed requirements.
