The conversation around prior authorizations (PAs) is growing louder as healthcare providers, patients, and policymakers alike confront the mounting challenges in accessing timely care.
A recent Senate report highlights how major Medicare Advantage (MA) insurers, covering nearly 60% of enrollees, are under scrutiny for their PA practices, especially concerning post-acute care services like home health and skilled nursing facilities.
At Onpoint, we believe it is time to address the intersection of innovation, regulation, and care delivery. By implementing thoughtful, AI-enhanced solutions, stakeholders can streamline the authorization process and reduce friction in care pathways, ensuring that patients receive the medically necessary services they need.
Key Findings: What the Data Tells Us
The Senate investigation reviewed over 280,000 documents from Humana, UnitedHealthcare, and CVS (Aetna), revealing patterns that have sparked concerns:
- UnitedHealthcare’s post-acute care PA denials increased from 10.9% in 2020 to 22.7% in 2022, correlating with expanded use of automated decision-making.
- Humana’s denials for long-term acute care hospital services surged by 54% between 2020 and 2022.
- CVS (Aetna) reported a 57.5% increase in PA requests for post-acute services over the same period, though its denial rate remained relatively stable.
The Potential and Pitfalls of Automation
AI and machine learning can offer significant benefits by reducing administrative burdens and expediting approvals. However, if applied without transparency or clinical rigor, these tools risk undermining care delivery.
At Onpoint, we understand the importance of using AI responsibly. Our Iris platform integrates natural language processing (NLP) to enhance workflows, making it easier for providers to navigate referrals and authorizations. Unlike systems that rely solely on automated decisions, our approach supports care teams by providing insights that inform, not replace, clinical judgment.
Moving Toward Collaboration and Transparency
In response to growing concerns, the Centers for Medicare and Medicaid Services (CMS) has proposed several key reforms:
- Improved data collection on PAs by care type to enable deeper analysis.
- Stricter timelines for PA decisions to reduce patient delays.
- Strengthened oversight of utilization management committees to ensure they meet compliance and equity standards.
Onpoint’s Value-Driven Approach
At Onpoint, we are redefining prior authorization workflows through our Iris Referral solution. Iris empowers healthcare organizations to overcome key barriers with features that ensure efficiency and continuity of care:
- Seamless Connectivity to Payers: Iris integrates directly with payer systems to automate and expedite authorizations, reducing delays caused by manual interventions.
- Closed-Loop Referral Management: Our platform ensures referrals are tracked to completion, enabling continuity of care and reducing the risk of missed follow-ups.
- Clinical Oversight for PA Approvals: When payer integration falls short, Iris leverages clinical resources to complete PAs in a timely manner, maintaining compliance and avoiding patient care disruptions.
For providers facing rising denial rates and evolving payer policies, these advanced capabilities translate into faster, more reliable authorizations and an improved patient experience. With Iris, healthcare teams can focus on what matters most: delivering exceptional care without administrative bottlenecks.
