Improving PA Outcomes

Prior authorizations—for procedures, high-tech imaging, and medications—often spark frustration, and understandably so. Providers see them as barriers, delaying care for patients who are sick or in pain, while insurance companies seem to deny requests without clear justification. At the heart of it, providers just want to deliver the care their patients need, fast. Yet, unclear requirements, denied requests, and the hassle of peer-to-peer reviews or appeals only add to the headache.

With over 25 years in healthcare, including 8 years focused on prior authorizations, I’ve seen the pitfalls firsthand. At ConsultStar, we’ve identified a key issue: incomplete or mismatched clinical documentation. Payers stick closely to their guidelines, often reviewed by non-clinical staff, or even AI, searching for exact matches between criteria and notes. If the language or format doesn’t align, requests get flagged for further review, peer-to-peer discussions, or outright denials, even when the provider’s intent is clear.

Utilizing templates within Electronic Health Record (EHR) platforms can turn this around. By leveraging templates tailored to payer expectations, providers can document clinical details thoroughly and in the right format. We partner with clients to analyze payer feedback—what’s triggering requests for more info or denials—and refine those templates accordingly. This cuts down on rework, speeds up approvals, and reduces the need for appeals.

We also spot gaps before submission, flagging cases where requirements won’t be met so providers can address them upfront. And for those worried about extra clicks slowing them down? Using a scribe lets providers focus on patients while ensuring every detail is captured.