How do you measure the value and benefit of prior authorization in utilization management?

1 PA and UM objectives

PA and UM share some common objectives, such as reducing unnecessary utilization, improving patient safety, and promoting evidence-based practice. PA can support UM by providing a mechanism to review and approve the most appropriate services for each patient, based on clinical guidelines and best practices. PA can also help UM by identifying and preventing potential overuse, misuse, or abuse of health care resources, such as duplicate tests, inappropriate procedures, or excessive prescriptions.

2 PA and UM challenges

However, PA and UM also face some challenges, such as administrative burden, provider dissatisfaction, and patient access. PA can create a significant workload for both providers and insurers, who have to submit, review, and process PA requests. PA can also cause frustration and dissatisfaction among providers, who may perceive PA as a barrier to their clinical autonomy and decision-making. PA can also affect patient access and continuity of care, especially if PA delays or denies the delivery of needed services or medications.

3 PA and UM solutions

To overcome these challenges, PA and UM need to implement some solutions, such as streamlining workflows, enhancing communication, and leveraging technology. PA and UM can streamline workflows by reducing the number of services that require PA, standardizing the PA criteria and forms, and simplifying the PA process. PA and UM can enhance communication by providing clear and timely feedback, educating providers and patients about the PA rationale and requirements, and resolving disputes and appeals. PA and UM can leverage technology by using electronic PA systems, integrating PA with electronic health records, and applying data analytics and artificial intelligence to support PA decision-making.

4 PA and UM metrics

To measure the value and benefit of PA in UM, you need to use some metrics, such as utilization rates, cost savings, quality indicators, and satisfaction scores. Utilization rates measure the volume and frequency of services or medications that are requested, approved, or delivered under PA. Cost savings measure the amount of money that is saved or avoided by using PA to prevent unnecessary or inappropriate utilization. Quality indicators measure the impact of PA on patient outcomes, such as safety, effectiveness, and satisfaction. Satisfaction scores measure the level of satisfaction or dissatisfaction among providers, insurers, and patients with the PA process and results.

5 PA and UM best practices

To maximize the value and benefit of PA in UM, you need to follow some best practices, such as aligning PA with UM goals, engaging stakeholders, and evaluating performance. Aligning PA with UM goals means ensuring that the PA criteria and policies are consistent with the UM objectives and standards. Engaging stakeholders means involving providers, insurers, and patients in the design, implementation, and improvement of the PA process. Evaluating performance means monitoring and analyzing the PA metrics and outcomes, and making adjustments as needed.

PA is a key component of UM, but it also poses some challenges. By using the indicators and outcomes discussed in this article, you can measure the value and benefit of PA in UM, and identify the areas that need improvement. You can also apply the solutions and best practices suggested in this article, to enhance the efficiency, quality, and satisfaction of PA in UM.