Simplifying Prior Authorization: Happier Patients and Providers

Shockingly, 94% of physicians say prior authorizations delay patient care - it's time for a change.

What is Prior Authorization? 

Prior authorization requires healthcare providers to obtain approval from insurers before delivering medical services. The process involves submitting detailed patient information and justifying the proposed treatment, after which insurers determine if the service is medically necessary and covered under the patient’s plan. 

When first introduced, prior authorization aimed to control access to new, expensive medications and treatments just entering the market. While its scope was limited, providers still had to navigate mountains of paperwork, send countless faxes, and spend hours on phone calls to secure approval.

In 2023, 78% of patients reported abandoning treatment due to prior authorization challenges.

Today, prior authorization has expanded dramatically - to include even generic medications. Now, instead of solely focusing on determining the best course of action to diagnose or treat a patient’s condition, providers must predict which treatments will be approved. In many cases, doctors don’t know whether a prescribed treatment will be covered or if it requires prior authorization until the patient arrives at the pharmacy. 

It’s no surprise that 95% of providers report that prior authorization somewhat or significantly increases physician burnout.

Nearly 1 in 4 providers report that prior authorization delays have resulted in serious adverse events for their patients.

How Citrus Reduces the Prior Authorization Guesswork

Citrus-affiliated providers note that “for treatments that do require prior authorization, it’s a frustrating guessing game,” and since they don’t know what the insurer is looking for, providers often submit extensive explanations. But if the documentation doesn’t perfectly align with what the health plan employee is looking for, then it gets denied. 

Our models analyze billions of medical and pharmacy claims to accurately identify which medications have been approved in the past, for which patients, and under what specific conditions.

We partnered with a provider system in San Antonio, Texas, to implement Citrus Patient Similarity. Using our machine learning framework, we created a digital clone for each patient by examining the healthcare interactions of similar patients at the same stage in their care journey. 

We worked with a patient suffering from moderate to severe eczema, whose life had significantly improved after starting Dupilumab. When a prior authorization got triggered, a Citrus-affiliated doctor completed the necessary paperwork, highlighting the patient’s remarkable progress on the medication. Despite this, the payer denied coverage, citing that the patient no longer met the severity criteria. 

In response, we collaborated with the provider to analyze medical and pharmacy claims alongside electronic health records (EHRs), uncovering patterns in similar patients’ diagnoses, treatment plans, and medication use.

Our analysis revealed that over half of patients with moderate to severe eczema have been treated with Dupilumab as a first-line therapy in the past five years, showcasing sustained efficacy and a favorable safety profile. By 30 to 36 months, 50% of these patients required no additional medications, compared to only 15% at the start of treatment. Moreover, over 80% saw symptom relief, and 3 out of 4 patients reduced follow-up visits by up to 33%. These findings enabled the provider to present a strong case for Dupilumab, demonstrating not only significant patient benefits but also cost savings for payers - reaching as much as $4,000 per case. As a result, we successfully reactivated coverage within a week. 

On Your Side: How Citrus Empowers Patients and Providers

• Streamlining Submissions: Citrus Provider Pulse seamlessly integrates with EHR systems, automatically extracting relevant data to complete authorization forms effortlessly. Our approach cuts processing times by 30%-45%, saving providers 10-30 minutes per request - equating to several days each month. 

• Enhanced Decision Support: Citrus Care Connect equips providers with tools to assess treatment appropriateness, enabling accurate, justified prior authorization requests. This results in a 25%-30% reduction in rejections and appeals. 

• Automation for Efficiency: By automating time-consuming manual tasks, Citrus reduces labor costs by thousands of dollars while lowering error rates by up to 50%. 

• Faster Patient Care: Patients benefit from a 65%-70% reduction in wait times, with approvals taking days instead of weeks. 

• Easier on the Wallet: Citrus saves thousands of dollars in unnecessary or overpayments at every level - patients, providers, and payers - while driving significant improvements in satisfaction. 

With Citrus, healthcare becomes faster, more efficient, and cost-effective for all stakeholders. Ready to transform your approach? Discover what Citrus can do for you today.