Payers use prior authorization programs selectively to ensure the appropriateness of care delivered and protect member safety.  

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Key Challenges

For payers, challenges to managing PAs include:

  • Difficulty for providers to confirm the services that require PA

  • Lack of standardized information requirements makes it difficult for providers to understand the required information and results in callbacks for further information

  • Consistent application of medical policies and evidence-based guidelines to each PA

  • High clinical staffing burn due to long worked hours to meet decision turnaround times

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Key Opportunities 

  • Reduce staff burden by 70% or more

  • Increase provider satisfaction through real-time determinations and auto approvals

  • Ensure clinical appropriateness through EMR/EHR agnostic clinical data fetch that reduces case review times

  • Improve case turnaround times and compliance

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  • Increased provider satisfaction through real-time determinations and auto approvals

  • Clear communication of prior authorization requirements and denial rationale

  • Eliminate the need for prior authorization intake and case creation

  • Reduced nurse review time

  • Significant reduction in case turnaround times

  • Improved decision support inter-rater reliability

  • Higher employee satisfaction

Ready to save? Click here to learn more about Smile's Prior Authorization solution.


*Case review cost attributed to inpatient specialty services as experienced by one Midwest Commercial Plan.

**Assumes an average case review time of 23 minutes.