By Dr. Steve Kim, Valer Co-Founder and CEO
This is Part 4 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 determined that prior authorization is required for a service. They’ve confirmed which payer is responsible. Now comes what should be a simple next step: submitting the authorization request.
Except it’s not simple at all.
We’ve mapped over 900 individual payer portals and fax forms for prior auth submissions—and this fragmentation represents just a portion of the total market, based on the provider organizations we already serve. Each portal has its own login credentials, documentation requirements, and technical quirks. Some payers accept electronic submissions through APIs (and, contrary to expectations, it will likely not be all of them for a while). Others require manual portal entry. Many still rely primarily on fax machines in 2025.
This fragmentation isn’t just an inconvenience. It’s a fundamental barrier to efficiency that forces patient access teams to become experts in hundreds of different submission systems, each with its own rules and frequent changes.
Challenge #1: Compounding Submission Challenges
The sheer number of submission pathways creates an impossible training and workflow challenge. A typical health system contracts with dozens of payers, but those contracts translate into hundreds of different submission routes depending on the specific plan, service line, and patient characteristics.
Patient access staff must remember (or constantly look up) which portal to use for each payer, maintain separate login credentials for each system, and navigate completely different user interfaces and submission workflows. When a staff member takes time off or leaves the organization, their knowledge of these varied systems walks out the door with them.
The fragmentation extends beyond just the sheer number of portals. Submission methods include:
- Payer-specific web portals with unique workflows
- Third-party clearinghouses with varying capabilities
- Direct fax submission to specific numbers by service line
- Emerging API connections with limited payer adoption
- Email submissions for certain delegated entities
- Phone-based submissions for expedited reviews
Each method has different documentation requirements, formatting expectations, and processing timelines. What works for one payer may not even be an option for another.
The solution: Consolidate your prior authorization workflow through a single platform that standardizes the submission process regardless of the underlying payer requirements. Look for solutions that maintain connections to all your payer portals and automatically route submissions to the correct destination without requiring staff to manage multiple logins and workflows.
Challenge #2: Contractual Complexity and Decision-Maker Ambiguity
Knowing which portal to use is only half the battle. Staff must also determine the exact contractual relationship that governs each authorization—and this can vary based on rendering facility, specific plan benefits, and provider Tax Identification Number (TIN) contracts.
The same patient, with the same insurance card, might require completely different submission paths depending on which service is rendered. An authorization for outpatient surgery at your hospital-owned facility might go through one portal, while another procedure may require submission through a different system entirely.
Compounding this complexity is the question of who actually makes the authorization decision. Is it the primary payer listed on the insurance card? A contracted third-party benefit manager the payer has engaged (eviCore, Carelon, Cohere, Availity, etc)? Requirements and decisions based on employer specific plan benefits and contracts? Staff often discover they’ve submitted to the wrong entity only after days of waiting, forcing them to start the process over with the correct decision-maker.
This ambiguity creates a trial-and-error dynamic where the only way to confirm the correct submission path is to attempt it and see if it works. Each misdirected submission adds days to the authorization timeline and increases the risk of patient care delays.
The solution: Work with partners who maintain detailed mapping of payer delegation relationships and contractual submission requirements to avoid blind spots. Actively cataloguing and maintaining this intelligence is beyond what most individual health systems can manage internally, but it’s critical for efficient authorization processing.
Challenge #3: Portal Instability and Technical Barriers
Even when staff know exactly where to submit an authorization, technical issues create constant disruptions. Payer portals experience regular outages, often without advance notice or clear communication about when service will be restored. During these downtimes, staff must resort to backup methods like fax submission, which may have different documentation requirements and processing timelines.
Portal design itself creates barriers. Many payer portals feature outdated user interfaces with confusing navigation, unclear error messages, and workflows that don’t match how patient access teams actually work. Forms may time out before staff can complete them, requiring them to start over and re-enter all information. File upload limits may prevent staff from submitting all required documentation at once.
Multi-factor authentication, while necessary for security, creates additional friction. Staff who work across multiple payer portals throughout the day find themselves constantly locked out or timed out, requiring password resets and authentication steps that consume significant time. When multiple team members share portal access under institutional credentials, these security measures can inadvertently lock entire teams out of critical systems.
The lack of API fallback options means that when portals fail, there’s often no reliable alternative submission method that maintains the same data quality and processing efficiency.
The solution: Prioritize prior authorization platforms that provide redundancy and backup submission pathways when payer portals are unavailable. Technology solutions should absorb the impact of payer technical issues rather than passing those disruptions directly to your staff.
Challenge #4: The Constant Change Problem
Just when your staff master a payer portal, the payer changes it. These changes happen with surprising frequency and often without adequate advance notice or training for provider users.
Payers modify their portals for various reasons:
- Upgrading to new technology platforms
- Changing web portal vendors
- Moving specific service lines to delegated TPAs
- Responding to regulatory requirements
- Modifying documentation requirements
Each change requires your staff to relearn submission workflows, update saved credentials and bookmarks, and adjust their mental maps of which portal handles which services. For patient access teams already stretched thin, these constant adaptations add to the cognitive load and create opportunities for errors.
Some changes are more disruptive than others. When a payer moves a service line from their internal authorization process to a delegated TPA, staff must not only learn a new portal but also update their understanding of which entity is responsible for which services. These transitions often involve periods where neither the payer nor the TPA seems to have complete information, leaving providers caught in the middle.
The solution: Choose technology partners who actively monitor payer portal changes and update their systems accordingly, rather than expecting your staff to track and adapt to hundreds of payer modifications. The maintenance burden of keeping current with payer changes should be handled by specialists, not distributed across every patient access team member.
Moving Toward Consolidated Workflows
While the industry is moving toward greater standardization, the reality is that fragmentation is likely to persist for the foreseeable future. Payers maintain different systems and processes to support their own internal approvals, and the transition to standardized APIs is happening slowly and unevenly.
Rather than waiting for industrywide standardization, provider organizations need solutions that consolidate fragmentation on their end. The goal isn’t to eliminate the hundreds of portals—it’s to shield your staff from having to navigate them directly.
Next up in Part 5: How provider and facility data matching requirements create a precision challenge where small errors lead to costly denials—and why getting the exact contracted combination right is harder than it sounds.
