Brilliant Care | Prior Authorization Management

Few things are as universally disliked in healthcare as prior authorizations (PAs). These are the requirements from insurance companies for providers to get approval before certain medications, tests, or treatments will be covered. Prior Authorizations are notoriously time-consuming and can delay patient care. A 2022 AMA survey found that on average, physicians and their staff spend roughly 13–14 hours per week on prior authorizations. – that’s nearly two full business days lost to paperwork and phone calls! Moreover, 40% of physicians have staff who work exclusively on Prior Authorizations, illustrating what a burden this is. Brilliant Care steps in to take over this administrative headache through our Prior Authorization Management service.

What we do

Prior Authorization Request Intake

We monitor for any triggers of prior auth needs. This could be:

An order placed in the EHR for a test or referral that requires Prior Authorization.
A pharmacy rejection notification for a prescription (“requires prior authorization”).
Direct communication from your staff (“Dr. Jones wants to start Drug X, which usually needs Prior Authorization, please handle it.”).

We make sure there’s a channel where all Prior Authorization needs are funneled to us promptly. Time is of the essence with Prior Authorizations, because any delay can mean the patient waiting longer for their medication or procedure.

Gathering Information

Our team collects all necessary info for the Prior Authorization. We retrieve the relevant clinical notes, lab results, imaging, or whatever justification is needed from the chart. If additional info is needed from the provider (like answering specific questions on a form), we reach out with clear, concise questions.

Form Submission / Portal Use

We complete the prior authorization forms – whether it’s on paper, via a payer’s web portal, or by calling the insurance’s Prior Authorization department. We articulate the medical necessity using the insurer’s criteria language when possible (we are experienced with the common ones – for example, what criteria must be met for an MRI approval, or a Tier 3 medication approval). Our goal is to get approval on the first submission by being thorough and aligned with criteria.

Follow-Up and Appeals

We track the status. If additional documentation is requested, we obtain it. If a Prior Authorization is denied and the provider wants to appeal, we facilitate the appeal process – including preparing appeal letters referencing clinical evidence or guidelines to support the request. In some cases, we schedule peer-to-peer discussions for the provider (and even prep them for it with key talking points based on denial reason).

Patient and Provider Communication

We keep all parties informed. If a patient is waiting on a Prior Authorization for, say, an MRI, we or the practice can update them: “We are working on your insurance approval; it should take X days.” If a particular alternative is needed (insurance says “we’ll approve Drug B instead of Drug A”), we notify the provider and assist with next steps (maybe the provider agrees to switch – we can then get that going for the patient).

Efficiency and Persistence

Our team is persistent. Prior auth often means long hold times on phone or repeated faxes – we handle all that behind the scenes, so your staff doesn’t have to. Because we focus on these tasks, we often turn them around faster. And we keep metrics – average time to resolution, approval rate, etc.

Impact on Practice

By outsourcing Prior Authorization management to us, your practice frees up significant staff and provider time. The AMA data indicates practices complete ~45 prior authorizations per physician per week on average. Imagine removing the majority of that workload from your team – they can redirect energy to patient-facing tasks and reduce after-hours work. Another survey found that prior auth burden leads to delays in care and can even result in patients abandoning recommended treatments due to hassle. We strive to minimize those negative effects by handling Prior Authorizations swiftly and smoothly, so care moves forward.

Reducing Care Delays

We can’t eliminate prior auth requirements, but we can mitigate their impact. Our timely management means the turnaround for approvals is as short as possible. This helps avoid scenarios where a patient is waiting weeks to start a needed medication. It also reduces the chance of care gaps – for example, 35% of physicians report that Prior Authorizations often lead to patients abandoning a recommended course of treatment (likely because of delays or confusion). With our team actively navigating the Prior Authorization, patients are more likely to actually get the treatment rather than give up in frustration.

Staff Satisfaction

Just as importantly, your staff will be relieved. Nurses and office staff often list Prior Authorizations among their most frustrating tasks. By handing these off to us, you improve your team’s job satisfaction. They know the Prior Authorizations are being handled by experts, and they can focus on direct patient care or other duties.

Provider Satisfaction

Similarly, providers feel better knowing Prior Authorizations are less of a thorn in their side. We keep them in the loop only as needed. If a peer-to-peer is required (since only a provider can do those calls), we schedule it conveniently and prepare everything for them – many times the provider just needs to reiterate points we’ve already provided in written form. So even the inevitable parts they must do are made easier.

In effect, our Prior Authorization Management service acts like a shield, absorbing the administrative onslaught so your practice doesn’t have to. The result is faster approvals, uninterrupted patient care, and a happier clinical team. The cost of not managing Prior Authorizations well is high – treatment delays, lost revenue (if things get dropped, you may not be able to bill for a service you recommended but never got authorized in time), and morale drain. We prevent those costs.

We stay up to date on changing payer rules and integrate feedback from past cases to constantly improve our success rate. We celebrate when an approval comes through for a complicated case because we know that translates to a patient getting the care they need.

In summary, with Brilliant Care handling your prior authorizations, you can almost forget that dreaded phrase exists. Your patients will get their care authorized faster, your staff will be free from hours on hold with insurance, and your providers will see their treatment plans realized without as many hurdles. It’s about smoothing the path between physician decision and patient treatment – we take care of the red tape so you can take care of the patient.