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Answer just a few questions to see where you stand. From there, you can
Understand PA’s implications across five key performance metrics.
Get ideas to raise your game with effective governance levers.
Learn how to improve your odds and build a winning hand.
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What is the overall ROI of your PA program?
Positive: goal achieved
Slightly positive
Break-even
Negative
I don’t know
Please choose a response and click “Next.”
Which of the following capabilities have you implemented to improve your PA processes?
Select all that apply
Automated letter generation
Provider web portal
Rules-based auto approval
AI-assisted documentation review
AI-assisted case creation
ePA using a FHIR-based API
1-2 days
5+ days
3-5 days
What is your average turnaround time for a standard PA request?
1-2
5+
3-4
On average, how many PA requests do clinicians process per hour?
Anecdotally
Data-driven: segmented detailed data
Data-driven: high-level summary
How are you measuring provider abrasion?
No
Yes: segmented detailed data
Yes: high-level summary
Do you have reporting that provides health equity insights for your PA program?
Not at all
Measure short- and long-term outcomes
Measure short-term outcomes only
To what extent are you measuring the effect of your PA rules on clinical outcomes?
Maturity levels
My results
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How to advance
Raise the stakes (competitive): Your health plan has some automation capabilities and reporting tools that help achieve cost savings, enhance member and provider experiences and improve outcomes. Room remains for further innovation.
See how your program ranks across individual UM transformation pillars.
Explore other program maturity levels.
Review your results.
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Your results
Industry leader
Competitive
Foundational
All in
Raise the stakes
Table stakes
Medical spend
Admin spend
Member experience
Provider experience
Clinical outcomes
Your health plan may have high administrative costs that are driving down program ROI, caused by highly manual processes leading to low productivity and slow turnaround times.
Conduct a PA process analysis to identify opportunities to introduce automation and improve efficiency, resulting in reduced manual burden and administrative spending.
Your health plan has low or negative program ROI due to PA rules that miss opportunities to reduce inappropriate medical spend.
Analyze the PA program’s ROI and adjust PA rules based on the identification of inappropriate medical spend that could have been avoided with clinical review.
Providers may be experiencing frustration from slow turnaround times caused by manual reviews. Your health plan does not have a systematic process to quantify and address abrasion.
Introduce ePA to alleviate provider administrative burden, while implementing metrics reporting and tracking to capture provider abrasion.
Members report negative experiences with extended turnaround times for PA requests and limited transparency. Your health plan may not currently have health equity insights on the PA program.
Identify opportunities to automate specific touchpoints in the PA process and align on health equity metrics to improve member experiences.
Your health plan does not consider the impact of PA rules on clinical outcomes and does not currently have a data-driven approach to measure and report metrics that may reflect these outcomes.
Implement a data-driven approach to assess how PA rules affect the intended clinical outcomes of requested services. Use these insights to enhance policies and directly improve outcomes.
Table stakes (foundational): Your health plan has manual processes for both PA review and data reporting, making it difficult to gain insights on health plan costs, member and provider experiences and long-term outcomes.
All-In
Your health plan tracks the effect of PA decisions on short-term clinical outcomes but fails to account for their long-term impact.
Broaden data sources, encompassing SDOH data to analyze the influence of PA rules on both immediate and long-term care member journey outcomes.
Members report mixed experiences with unsatisfactory turnaround times. Your health plan is beginning to address disparities through high-level health equity insights.
Identify opportunities to further automate your processes and segment health equity metrics to enable targeted interventions that meaningfully improve member experiences.
Your health plan has implemented strategies to measure and reduce provider abrasion, resulting in enhanced provider experiences. Targeted interventions remain challenging due to the absence of detailed segmented insights.
Measure provider abrasion through tracked metrics, and target interventions based on segmented analysis to enhance satisfaction and streamline processes for providers.
Your health plan has a positive program ROI resulting from PA rules that have succeeded at preventing and reducing inappropriate medical spend. But you’ve yet to reach organizational goals.
Conduct a holistic evaluation of PA rules, analyzing procedure code-level ROI and assessing PA’s impact on long-term medical spending to identify policy adjustments that achieve savings optimization.
While your health plan has implemented automation and process improvement strategies, opportunity remains for process adjustments that optimize handle times and reduce request turnaround times.
Use AI and ML technology such as optical character recognition, intelligent character recognition and machine translation to automate complex administrative and clinical tasks. Evaluate staff productivity to uncover efficiency opportunities that further alleviate administrative burdens.
Your health plan assesses the impact of PA decisions on member outcomes across the care journey, employing data-driven methods with real-time monitoring and predictive analytics for optimal results.
Use a multidimensional clinical framework that includes SDOH factors to proactively authorize care that ensures optimal member outcomes.
Members express high satisfaction with fast turnaround times facilitated by automated processes, coupled with transparent and equitable PA rules influenced by comprehensive health equity insights.
Power up PA processes with intelligent automation such as AI-powered virtual assistants and clinical decision support tools to provide industry-leading service.
Your health plan can assess provider abrasion at the individual physician level, enabling targeted and effective interventions that enhance provider satisfaction.
Expand provider intelligence through AI-powered reporting that forecasts the potential influence of PA processes on provider satisfaction and suggests interventions to mitigate provider abrasion.
Your health plan has achieved organizational ROI goals by optimizing the PA program to achieve maximum medical cost savings.
Broaden data sources for predictive analytics, enabling proactive authorization of suitable care, curbing wasteful spending by reducing PA volume and promoting optimal care choices.
Your health plan has fully streamlined administrative and clinical processes, using data-driven insights and AI-powered automation to reduce administrative spend and turnaround times.
Transform administrative and clinical review processes by implementing generative AI-driven predictive modeling that can provide immediate approval decisions to minimize manual work and administrative costs.
You’re all in (industry leader): Your health plan uses the latest technology to maximize automation and leverage near real-time data insights with PA to achieve cost savings, enhanced provider and member experiences and positive clinical outcomes.
