预授权正在消耗收入：为什么自动化已成为战略要务
Prior Authorization Is Draining Revenue: Why Automation Has Become a Strategic Imperative
预授权已成为医疗保健中最昂贵的行政瓶颈之一，其影响远不止于医生诊所。在医院和医疗系统层面，它减慢了患者就医速度，增加了劳动密集型工作，提高了拒赔风险，并对报销和现金流造成压力。对于关注增长、利润和运营韧性的组织而言，预授权不再仅仅是行政问题。这是一个具有企业级影响的前端收入周期挑战。
最近的美国医学会（AMA）调查数据显示，每位医生每周平均完成39项预授权申请，消耗至少13小时的员工时间。在许多组织中，医院和医疗团体不得不投入整个团队来处理授权管理和 payer 跟进。结果是日益增长的劳动负担，导致员工疲劳、流失，以及患者接入、利用管理和收入周期职能中运营成本的上升。
其影响远不止行政效率低下。预授权延迟可能扰乱医疗服务提供，减慢周转，并在整个患者体验中制造摩擦。根据AMA的数据，93%的医生报告因预授权要求而导致护理延迟，82%的医生表示患者因授权障碍而放弃推荐的治疗。对于提供者组织而言，这些延迟转化为可预防的拒赔、可避免的核销、延迟的报销以及代价高昂的行政返工。
由以下机构呈现赞助帖子自动化医疗实践内部：围绕人而非文书重新设计护理通过减少行政负担并围绕人类需求重新设计工作流程，它为最重要的事情创造了空间：临床医生与患者之间的联系。
作者：Michael Blackman, MD, MBA，Greenway Health®首席医疗官其影响意义重大。当员工超负荷工作且患者面临延迟或放弃护理时，问题不再仅仅是狭隘的行政负担。它变成了一个业务、财务和获取挑战，需要不同的运营模式。
为什么财务风险始于上游
挑战在于，预授权并不局限于收入周期的一个部分。它在服务提供之前就已开始，并影响后续所有环节，从预约和登记到报销和拒赔预防。由于 payer 要求不标准化、文档规则频繁变化，且团队必须同时管理多个变量，该流程仍然困难重重。
传统方法是为不太复杂的环境而设计的，过于依赖个人知识、手动跟进和员工的毅力。这造成了差异，使业绩更难预测，并在经验丰富的员工离职时使组织暴露于风险之中。仅仅增加劳动力并不能解决根本问题。更大的机会是在前端减少可避免的工作，并在授权问题造成下游干扰之前加以预防。
由以下机构呈现赞助帖子医疗支付行业面临认知挑战医疗支付不再是关于交易。它关乎控制收入周期。而且这种控制越来越多地不在ISO手中。
作者：Lisa Brooks，医疗合作伙伴关系副总裁自动化是RCM的要务自动化有助于组织从员工工作流程中移除重复性、基于规则的工作，并在更大范围内更一致地应用授权流程。AI可以通过帮助团队识别优先案例、更早地发现潜在风险，并将人类注意力集中在最重要的事情上来增强这一模式。其价值不在于为了自动化而自动化，而在于更好地控制劳动力、更快的周转时间、更少的可预防拒赔以及更强的财务表现。人工监督仍然至关重要。
提供者组织需要与 payer 侧自动化不同的方法。与其使用AI来缩小符合医学必要性的范围，提供者可以使用AI来支持工作流治理、标准化决策，并在请求到达 payer 之前提高准备程度。
如果有效使用，AI可以帮助团队更一致地识别授权要求，更可靠地应用 payer 规则，并提高对整个组织风险的可视性。这为领导者提供了对瓶颈、异常和 payer 延迟的更清晰视图，使他们能够更早采取行动，减少不必要的返工，并保护患者接入和报销。
市场已经在发出信号
市场已经在朝这个方向发展。CMS正在通过基于FHIR的API推进电子预授权，某些健康计划必须从2027年1月1日起实施和维护这些API。与此同时，主要 payer 正在减少一些授权要求。UnitedHealthcare 已宣布计划到2026年底取消30%之前需要审批的服务的预授权要求，而 Humana 则表示将取消约三分之一的门诊预授权要求，并在一个工作日内对至少95%的完整电子请求做出决定。
这些变化提高了提供者运营的门槛。随着 payer 和监管机构转向更快、更电子的授权流程，医院和医疗系统将需要内部工作流程、数据纪律和自动化能力来跟上步伐。更少的授权要求并不会自动使流程变得更简单。优势将属于那些能够将 payer 变化与前端工作流程对齐、在服务提供前减少摩擦、并从一开始就保护报销的组织。
提供者组织现在应该做什么
提供者组织应专注于标准化授权工作流程，减少人工差异，提高授权风险的可视性，并自动化那些拖慢员工速度的重复步骤。目标不是将人员从流程中移除，而是帮助他们在需要判断的例外情况、升级和决策上更高效地工作。
预授权正在成为一个战略性能力问题，而不仅仅是行政负担。现在进行现代化的组织将更有能力改善患者接入，减少可避免的收入流失，增强劳动力生产力，并在更加自动化的市场中更有效地竞争。
照片：Damon_Moss, Getty Images Terry Russell Terry Russell 是 Conifer Health Solutions 的实施与优化副总裁，负责领导专注于运营绩效、患者服务和医疗优化的战略举措。
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Prior authorization has become one of healthcare’s most expensive administrative bottlenecks, affecting far more than physician practices. Across hospitals and health systems, it slows patient access, adds labor-intensive work, increases denial risk, and puts pressure on reimbursement and cash flow. For organizations focused on growth, margin, and operational resilience, prior authorization is no longer just an administrative issue. It is a front-end revenue cycle challenge with enterprise-wide consequences.
Recent American Medical Association (AMA) survey data show physicians and care teams complete an average of 39 prior authorization requests per physician each week, consuming at least 13 hours of staff time. In many organizations, hospitals and medical groups have had to dedicate entire teams to authorization management and payer follow-up. The result is a growing labor burden that contributes to staff fatigue, turnover, and rising operating costs across patient access, utilization management, and revenue cycle functions.
The impact extends well beyond administrative inefficiency. Prior authorization delays can disrupt care delivery, slow throughput, and create friction throughout the patient experience. According to the AMA, 93% of physicians report care delays tied to prior authorization requirements, while 82% say patients abandon recommended treatment because of authorization obstacles. For provider organizations, those delays translate into preventable denials, avoidable write-offs, delayed reimbursement, and costly administrative rework.
By Michael Blackman, MD, MBA Chief Medical Officer, Greenway Health®
The implications are significant. When staff are overextended and patients face delays or abandon care, the issue is no longer a narrow administrative burden. It becomes a business, financial, and access challenge that demands a different operating model.
Why the financial risk starts upstream
The challenge is that prior authorization is not confined to one part of the revenue cycle. It begins before care is delivered and influences everything that follows, from scheduling and registration to reimbursement and denial prevention. The process remains difficult because payer requirements are not standardized, documentation rules change frequently, and teams must manage multiple variables at once.
Traditional approaches were built for a less complex environment and depend too heavily on individual knowledge, manual follow-up, and staff persistence. That creates variation, makes performance harder to predict, and leaves organizations exposed when experienced employees leave. Simply adding labor does not fix the underlying problem. The bigger opportunity is to reduce avoidable work at the front end and prevent authorization issues before they create downstream disruption.
Automation is an RCM imperative
Automation helps organizations remove repetitive, rules-based work from staff workflows and apply authorization processes more consistently at scale. AI can strengthen that model by helping teams identify priority cases, surface likely risks earlier and focus human attention where it matters most. The value is not automation for its own sake. It is better control over labor, faster turnaround, fewer preventable denials, and stronger financial performance. Human oversight remains essential.
Provider organizations need a different approach from payer-side automation. Rather than using AI to narrow what qualifies as medically necessary, providers can use it to support workflow governance, standardize decision-making, and improve readiness before a request ever reaches the payer.
Used effectively, AI can help teams identify authorization requirements more consistently, apply payer rules more reliably, and improve visibility into risk across the organization. That gives leaders a clearer view of bottlenecks, exceptions, and payer delays so they can act earlier, reduce unnecessary rework, and protect both access and reimbursement.
What the market is already signaling
The market is already moving in this direction. CMS is advancing electronic prior authorization through FHIR-based APIs, with certain health plans required to implement and maintain them beginning January 1, 2027. At the same time, major payers are reducing some authorization requirements. UnitedHealthcare has announced plans to eliminate prior authorization requirements for 30% of services that previously required approval by the end of 2026, while Humana has said it will remove about one-third of outpatient prior authorization requirements and provide decisions within one business day on at least 95% of complete electronic requests.
These changes raise the bar for provider operations. As payers and regulators move toward faster, more electronic authorization processes, hospitals and health systems will need the internal workflows, data discipline, and automation capabilities to keep pace. Fewer authorization requirements will not automatically make the process easier. The advantage will go to organizations that can align payer changes with front-end workflows, reduce friction before services are delivered, and protect reimbursement from the start.
What provider organizations should do now
Provider organizations should focus on standardizing authorization workflows, reducing manual variation, improving visibility into authorization risk, and automating the repetitive steps that slow staff down. The goal is not to remove people from the process, but to help them work more efficiently on the exceptions, escalations, and decisions that require judgment.
Prior authorization is becoming a strategic capability issue, not just an administrative burden. Organizations that modernize now will be better positioned to improve patient access, reduce avoidable revenue leakage, strengthen workforce productivity, and compete more effectively in a more automated market.
Photo: Damon_Moss, Getty Images Terry Russell Terry Russell is Vice President of Implementation & Optimization at Conifer Health Solutions, where he leads strategic initiatives focused on operational performance, patient services, and healthcare optimization.
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