Tracking Prior Authorization KPIs: What to Measure and Why?
What are the risks of not getting a prior authorization right? Unfortunately, there are many. When prior authorizations are not managed correctly, healthcare organizations can encounter delayed patient care and negative clinical outcomes, patient leakage and dissatisfaction, resource underutilization, and revenue loss. And the more manual your prior auth processes are, the higher these risks become.
If you’re hoping to centralize or standardize your operations, understand where your organization’s bottlenecks are, or convince your team that automation is the answer, you’ll need data first. Tracking internal prior auth volumes, staff and payer performance, overall process measures, and more allows healthcare organizations to optimize operational results, support negotiations with payers about performance and reimbursement, and get organizational buy-in for integrating automation.
In our latest webinar, The Wilshire Groups’ Tim Holland discusses how tracking four ‘need to know’ prior authorization KPIs can impact your organization.
1. Capacity Planning
The first step in tracking your prior authorization KPIs is understanding your organization’s prior authorization burden and how many staff members you need to support it. Start by analyzing the estimated volume of prior auths your organization performs monthly or weekly. Then, take a look at how many full-time employees (FTEs) are currently managing your authorizations and what their productivity is. How long is it taking them to complete each prior authorization submission? Is the average amount of authorizations too high or too low for the FTEs you have assigned?
This will help you understand if you could be handling more prior authorizations in a given period or if you could be using automation tools like Valer to help speed and standardize operations.
2. Staff Performance & Productivity
Once you have a handle on the total amount of work that your organization needs to accomplish, you can start to analyze what your team is actually able to do with the time they have. When you manually handle prior auth processes, tracking how much your staff is accomplishing can be difficult because so much of the work happens outside of the EMR/EHR. With tools like Valer, organizations can view granular data around staff performance and productivity.
The solution can track metrics such as the number of authorizations individual users can submit on a weekly basis, completed prior authorizations by service type and by staff member, average payer web portal submission times, and more. These types of data points can help optimize how your teams are running.
3. Payer Performance
A common frustration for healthcare organizations is the lack of certainty and clarity tied to payer requirements. Without standardization across the industry, you’ve likely been at the mercy of these requirements with very little insight into reasons for denials or turnaround times.
Because payer performance significantly impacts operational efficiency, revenue, and patient experience, it’s important to be able to track what you can. With Valer, providers can view average prior auth turnaround times by health plan and service type. The solution also provides insight into the CPT codes that payers routinely deny. This is critical to help prepare your team and account for those routine denials earlier in the prior auth process. This can also support your relationship with payers, ensuring you provide them with the information they need to verify a claim promptly.
4. Overall Process Measures
Additional prior authorization KPIs organizations should track include authorization days out, resolution rates, and denials or write-offs. For Valer clients like Oregon Health and Science University, their team tracked authorized days out before and after using Valer. They improved their days out from 5 to 13. Kern Medical’s team tracked authorization resolution rates before and after Valer with dramatic results: improving their resolution rate from 68% to 97%.
Creating a benchmark for these processes can give your organization a necessary and well-rounded look at your current workflows and allow your team to hone in on where there is room for improvement.
Ready to Support Your Prior Authorization KPIs
At Valer, we understand the importance of performance tracking and reporting to boost efficiency, improve operations, and support payer relationships. If your organization does not have KPIs in place to track your prior auth management, 2025 is the year to start benchmarking. It’s crucial to ask your solution provider about their reporting capabilities for prior auth processes, especially for the submission and verification portion.
If you’re interested in learning more about how we can support your prior authorization management and make it easier for you to track performance, contact us today. If you’re interested in learning more about the KPIs discussed in this blog, catch our webinar on-demand: What are the KPIs You Should Know for Prior Auth Management and Performance Evaluation?
