By Dr. Steve Kim, Valer Co-Founder and CEO
This is Part 1 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.
There’s a lot changing in the prior auth world. But one of the most consistent patterns we’ve seen revolves around workforce gaps at provider organizations. It’s common for 20% of patient access team members to handle 80% of the prior authorization workload, and for some team members to breeze through submissions while others struggle for 15 or 20 minutes with the same task.
These variances are not the fault of patient access teams. They’re the result of highly complex administrative work that doesn’t get enough credit—and requires significantly better workflows and data transparency to become manageable and efficient.
Gap #1: Lack of Specialized Expertise Required for Prior Auth
The most glaring disconnect lies in the skills mismatch plaguing frontline roles. Patient access teams are routinely expected to navigate complex clinical documentation and interpret intricate payer policies without clinical backgrounds or comprehensive training. They’re asked to make judgment calls about medical necessity, understand the nuances of diagnostic coding, and communicate with providers about clinical requirements—all while being classified as administrative staff.
By treating prior authorization as clerical administrative work rather than recognizing it as a strategic domain, organizations systematically underinvest in the specialized expertise and organizational infrastructure these roles actually require.
This misclassification cascades through every aspect of prior authorization management: from hiring decisions that prioritize administrative experience over clinical or healthcare-specific understanding, to training programs that focus on process memorization rather than decision-making skills, to technology investments that automate the wrong parts of the workflow.
The solution: Invest in clinical training and expert-driven resources for your patient access team, and work with vendors like Valer who pair solutions with industry knowledge and education.
Gap #2: Over-Reliance on “Tribal Knowledge’
High turnover rates create a vicious cycle that perpetuates inefficiency across patient access departments. When experienced staff leave due to frustration with constant rework and denial management, they take with them the institutional knowledge that made them part of that high-performing 20%. New hires enter an environment where they’re expected to learn complex, often contradictory workflows through trial and error, leaning heavily on “tribal knowledge” that may or may not be accurate or current.
This cycle isn’t just costly in terms of recruitment and training—it fundamentally undermines the consistency and reliability that effective prior authorization requires. When your workforce is constantly in flux, standardization becomes nearly impossible.
The solution: Prioritize visibility and goals to improve team performance and training processes. Start with monthly staff productivity reports, broken down by individual user and service line. Taking a data-driven approach isn’t about being punitive—it’s about having a clear line of sight into how your FTEs spend their time, and giving them credit for their full prior auth workload. With a detailed enough report, you can set operational goals for time spent per auth, as well as account for the true amount of training time needed to get team members to contribute their full share, efficiently.
Gap #3: Fragmented Prior Auth Processes
Even without the turnover trap, standardization is elusive because of the very nature of the prior auth landscape, which is incredibly fragmented with different submission rules for each payer, specialty, and service line—not to mention different regulations in each state that affect what providers should expect from payers’ ruling patterns. Each provider is essentially rebuilding prior authorization processes from scratch, based on their unique payer mix and internal workflows. This fragmentation means that lessons learned at one organization rarely transfer effectively to another, and best practices remain isolated rather than becoming industry standards.
The solution: The prior auth submission process needs to be simpler, period. That simplification starts with one streamlined workflow that works across all of your payers, specialties, and service lines and automates some of the most tedious and manual parts of the process. Valer’s platform gives staff one place to work all prior auths to make the process not just manageable, but efficient and sustainable for the whole team.
Next up in Part 2: How EHR technology mismatches create the perfect storm for prior authorization failures, and what provider organizations can do about it.
