Should prior authorization be centralized?

I can often tell how a practice handles prior authorizations by the way its leaders describe the problem.

If the work is centralized, the leader usually knows exactly how much staff is assigned to it. The problem sounds like headcount: We have this many people spending all day on prior authorizations, and we need them doing something more valuable. It's relatively easy to put a dollar value on the work because the people doing it are visible.

If prior authorizations are handled by different people around the practice, the problem is harder to pin down. Leaders describe the work as wading through mud. New staff are difficult to train. Nobody can say exactly how many hours the work consumes because it's scattered among medical assistants, scribes, front desk staff, DME staff, a billing company, and whoever else happens to know how to get a particular request done.

Those practices don't have fewer prior authorizations. The work is just hiding in more places.

What keeping the work close to the provider gets right

When a medical assistant or another person close to the provider handles an authorization, they have context that a centralized team can easily lose.

They may already have the patient's chart open, so there isn't a separate step to find the patient and reconstruct what happened during the encounter. They may know that an authorization will be required before the provider has even finished the note. If a peer-to-peer is needed, they're close enough to the doctor to schedule it and, in some offices, get on hold before having the doctor come over to take the call.

That proximity can make the work move quickly. It also turns prior authorization into one of many annoying tasks the staff member has to remember throughout the day.

Someone who does a few authorizations here and there is less likely to learn every payer's shortcuts, submission routes, and changing requirements. Jack of all trades, master of none applies here too. The same task may be performed differently for every provider, and every new employee has to be taught a process that might exist mostly in the heads of the people around them.

What centralization improves

Centralization creates specialization. A team that handles prior authorizations all day, every day learns to complete them more quickly and reliably than dozens of people who each do a few.

It also lowers the practice-wide training burden. Instead of teaching every medical assistant, scribe, and front desk employee how to navigate every payer, the practice can train a smaller group deeply.

The biggest advantage may be the ability to improve the process. A centralized team can identify a better submission route, learn a payer requirement, or fix a recurring mistake and apply that lesson to every future request. When the work is spread across the practice, the same improvement might have to be explained to dozens of people across several locations and then reinforced until everyone consistently remembers it.

Centralization also makes the work measurable. The practice can see the number of requests, the approval rate, how long cases take, where delays occur, and how much staff time is assigned to the process. It's difficult to improve work that the organization can't see.

The best model keeps initiation close to the action

The choice doesn't have to be between moving all prior authorization work to one team and leaving all of it with staff close to the provider.

The best of both worlds is often to let the people close to the provider identify or initiate the request, then have a centralized team complete and manage it. The provider's staff preserve their clinical context and speed. The centralized team provides specialization, consistency, and coverage.

Exactly what that looks like depends on the practice.

In a retina practice where nearly every specialty drug requires authorization, a centralized team may be able to look at the upcoming schedule and identify the work without anyone handing off each individual request.

Orthopedics can be different. A surgeon's assistant may need to initiate an authorization for outside imaging as soon as the provider decides to order it. There won't necessarily be an MRI encounter on the practice's own schedule for a centralized team to discover later. If nobody explicitly recognizes and hands off the request, it can slip through the cracks.

In a theoretical world with unlimited staff time, someone could read every note, understand every payer requirement, and identify every authorization automatically from the clinical record and schedule. In the real world, the process depends on recognizing that an authorization is needed. When that recognition is uncertain, reducing unnecessary handoffs helps.

When a handoff is necessary, the request must become traceable. With Davner, it becomes a case that the practice can follow. Without Davner, it should at least become a task in the EHR or another system of record. It can't live in a conversation, a sticky note, or someone's memory and then disappear into the ether.

Centralization can create new failure points

The biggest failure mode of a centralized service is the extra step required to get work into it. If the handoff isn't reliable, centralization can create a well-organized team that doesn't know a patient is waiting for an authorization.

A small centralized team can also become fragile. If “centralization” means one employee does every authorization, that person's vacation or sick day can bring the process to a halt. The practice has concentrated its knowledge but hasn't created real coverage.

Urgent cases can also become just another item in a central queue. A medical assistant sitting beside the provider may know that a procedure needs to happen immediately. A centralized employee in another building only knows what the request tells them. The workflow needs a reliable way to identify STAT cases and move them to the front.

Davner is able to operate as an outsourced centralized prior authorization service without putting the entire responsibility on one person. Practices with a centralized team or billing company can send requests to us. Individual medical assistants can also request an authorization the moment they learn it's needed.

Team members can identify a request as STAT, and Davner also uses the upcoming date of service to recognize cases that need immediate attention. The centralized work still depends on good information from the practice, but it doesn't have to depend on one employee being present that day.

Internal centralization requires real investment

Centralizing internally usually means reassigning staff, reorganizing responsibilities, or hiring more people. At best, it requires organizational flexibility.

Hiring someone with a revenue cycle management background doesn't necessarily mean they know how to perform prior authorizations. The practice still needs robust training, documented procedures, enough coverage, and management capable of improving the system over time.

The physical setup matters too. One of the biggest productivity improvements we've seen is giving authorization staff multiple large monitors. They can keep the patient's clinical record open on one screen and the payer's submission portal on another instead of switching back and forth and trying to remember information. That sounds small until it's multiplied by every field in every request throughout the day.

Space can become a real consideration. Medical assistants may already sit near their associated doctors. A centralized group needs somewhere to work, the right equipment, and a staffing model that continues functioning when someone is absent.

Whether to build that internally or use an outsourced service depends on the practice's ability to hire, train, equip, cover, and manage the team. Moving everyone into the same room doesn't create a successful centralized process by itself.

Start by finding the work

Before hiring anyone, buying anything, or reorganizing the practice, get a handle on the quantity of prior authorization work already happening.

Find every place it lives. Medical assistants may be handling some requests. The DME department may be handling others. A billing company might be doing another category. Specialty medications, imaging, and surgeries may each follow completely different paths.

From there, determine how quickly requests are submitted and approved, how often mistakes occur, and how much staff time the work takes. For some practices, the revenue lost from one missed authorization can far exceed the cost of the employee assigned to check the work. Centralization should improve speed and approval rates, decrease mistakes, create reliable coverage, and give leadership enough visibility to keep making the process better.

If your practice doesn't have a prior authorization team, prior authorizations didn't disappear. They're being done somewhere. The first step is finding out where.