KD-024 · Workflow

Prior Authorization Current State

Make the manual reconciliation, tacit judgment, and exception paths in a typical prior-authorization flow visible for assessment.

Evidence level: Experience based
Executive audience: Prior-authorization leader, provider operations leader, COO
Publication status: Published after human review

Inspect the operating model

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Text alternative and Mermaid source

Prior Authorization Current State. Make the manual reconciliation, tacit judgment, and exception paths in a typical prior-authorization flow visible for assessment. Business problem: Administrative burden accumulates when intake, documentation, payer requirements, and exception routing are not explicit in one operating model. Claim boundary: Illustrative operating model drawn from advisory experience. It does not establish a client outcome, payer rule, clinical guidance, legal advice, compliance certification, volume, savings, or turnaround-time result.

flowchart LR
  I[Intake] --> D[Documentation assembly]
  D --> P[Payer requirements checked]
  P --> X{Standard path?}
  X -->|No| H[Experienced person reconstructs exception]
  H --> E[Informal escalation]
  X -->|Yes| S[Submit]
  E --> S
  S --> F[Follow-up and rework]

Why this matters

Administrative burden accumulates when intake, documentation, payer requirements, and exception routing are not explicit in one operating model.

Executive decision

Identify where work leaves the standard path and what evidence, ownership, and escalation must become explicit before automation.

Claim boundary

Illustrative operating model drawn from advisory experience. It does not establish a client outcome, payer rule, clinical guidance, legal advice, compliance certification, volume, savings, or turnaround-time result.

Evidence summary

healthcare:ev-healthcare-pa-operational-burden

Authorization exceptions depend on specific individuals knowing where to route a case; when those individuals are unavailable, the case waits and administrative burden accumulates silently.

Boundary: Advisory experience; pattern not metric; no orgs named.

healthcare:ev-healthcare-human-api-dependency

Across prior auth, UM, care management, interoperability, regulatory, and transformation work, the same root cause recurs: critical operational knowledge lives inside individuals instead of governed systems.

Boundary: Advisory experience; the through-line for all healthcare proof. Pattern not metric.