Russell Graney, Founder and CEO of Aidin, argues that simply speeding up the prior authorization process will not resolve the underlying issues in healthcare. This long-standing challenge has become a significant source of frustration for doctors and patients alike, often leading to delayed treatments and unnecessary complications. Graney highlights that while automation and artificial intelligence (AI) are frequently touted as solutions, they do not address the core misalignment between the incentives of payers and providers.
Understanding the Prior Authorization Challenge
The term “prior authorization” is notorious in the medical community, evoking images of prolonged waits and endless paperwork. For clinicians, the process often drains valuable time and energy, while patients may experience deteriorating health due to treatment delays. In the eyes of insurers, prior authorizations serve as a tool to manage costs and enforce compliance, but the method can create tension with healthcare providers who are striving to deliver timely care.
Graney emphasizes that the inefficiencies in prior authorization stem not from the speed of the process but from fundamentally conflicting goals. Clinicians prioritize timely treatment, while payers focus on cost containment. This disconnect results in a cycle of frustration, where patients are left waiting for approvals that can significantly impact their health outcomes.
The Impact of Technology and Automation
There’s a growing belief that technology, particularly AI, can alleviate the burdens of prior authorizations. Currently, the process consumes an average of 12 hours of staff time weekly. Automating approvals could theoretically streamline this burden. However, Graney warns that introducing automation into a misaligned system may only exacerbate existing problems.
“If the underlying workflows remain misaligned, scaling just compounds the wrong outcomes,” Graney asserts.
He points out that while automation can facilitate faster processing, it also risks increasing the rate of denials and duplicate requests. As teams grapple with more exceptions and resubmissions, the time spent on patient care diminishes. Consequently, this technological leap could lead to more administrative headaches rather than a resolution.
Graney uses an analogy to illustrate this problem: “Imagine paving a six-lane highway between two cities without agreeing on which side of the road to drive on.” In this scenario, speeding up the process increases the risk of accidents rather than improving safety and efficiency.
Rethinking the System: People, Processes, and Technology
To genuinely improve the prior authorization process, Graney suggests a fundamental shift in the order of operations: prioritize people, then processes, and finally technology. The healthcare sector often jumps straight to implementing new technologies without addressing the foundational issues.
All stakeholders—patients, providers, and payers—need transparency and accountability. Trust can only be established when everyone operates under the same set of rules, which should be applied consistently. This collaborative environment can help resolve disputes more effectively and reduce unnecessary delays.
Moreover, redesigning workflows to promote collaboration rather than competition is essential. When each party focuses solely on its interests, automation merely speeds up conflicts. By aligning processes around shared goals, such as ensuring timely access to quality care, the friction can be reduced, leading to better outcomes for everyone involved.
Only after these foundational aspects are addressed can technology truly add value. With aligned systems, automation can evolve into partnerships that support clinicians and streamline approvals, thereby enhancing patient care.
Leveraging AI Effectively
While AI holds promise, it should be employed within well-aligned workflows. Inappropriately applied, AI can reinforce existing silos and amplify inefficiencies. For instance, if two departments unknowingly submit the same request, automation could permit both to proceed without scrutiny, clogging the system instead of fixing it.
In the right context, AI can improve transparency and decision-making. It can identify duplicate requests, highlight exceptions needing human attention, and expedite routine approvals that have already garnered consensus. When technology aligns with a cohesive system, the process becomes more reliable and easier for all parties involved.
Prior Authorization as a Reflection of Broader Issues
Graney views prior authorization as a warning light indicating deeper systemic problems within healthcare. The same inefficiencies that delay approvals also hinder referrals and complicate transitions of care. For example, a physician may secure an approval, only to face new barriers when transferring a patient to the appropriate facility. Each of these steps can create additional waiting periods for patients.
Addressing prior authorization in isolation misses the broader opportunity to align incentives across the entire continuum of care. By fostering shared accountability among payers, providers, and post-acute partners, the healthcare system can facilitate faster authorizations and smoother transitions for patients.
In collaborations with major health systems, Graney observed that care managers gained better control over the prior authorization process. This led to improved visibility into request statuses, denial rates, and turnaround times. With these insights, healthcare providers not only protect patients from delays but also bolster their position in payer negotiations.
Conclusion and Future Directions
For those developing healthcare solutions, Graney stresses the importance of addressing systemic issues rather than merely adding new tools. Aligning incentives, building governance into the healthcare framework, and fostering collaborative environments are essential steps. Speed may be desirable, but fairness, transparency, and accountability are paramount.
Ultimately, the goal should be to create a healthcare system that ensures patients receive the right care at the right time, consistently. By focusing on trust-based relationships and shared responsibility, the healthcare community can transform the prior authorization process into a more efficient and humane experience for all.
Russell Graney is the Founder and CEO of Aidin, a platform dedicated to enhancing care management and improving transitions of care. His background includes experience at Bain & Company and a personal motivation to improve healthcare systems, stemming from his uncle’s diagnosis of early-onset Alzheimer’s.
