Patient-Level Authorization: The Future of Care Access

Did you know that 88% of physicians report that prior authorization requirements lead to delays in patient care?

This administrative hurdle often creates a significant barrier, affecting both patient outcomes and provider efficiency. Patient-Level Authorization (PLA) offers a modern solution to streamline this process, shifting the focus from individual services to the patient as a whole. This guide explains what PLA is, how it works, and why it is becoming essential for modern healthcare.

What is Patient-Level Authorization (PLA)?

Patient-Level Authorization is a new approach to healthcare approvals. Instead of requiring a separate authorization for every single test, procedure, or prescription, PLA allows for a single, comprehensive authorization for a patient’s entire course of treatment. This approval is based on the patient’s specific diagnosis and the established clinical care path for that condition. By consolidating multiple authorization requests into one, PLA significantly reduces administrative workload and helps patients get the care they need faster.

How the Patient-Level Authorization Process Works

The PLA process is designed to be more efficient and patient-centric than traditional authorization methods. Here’s a typical workflow:

1. Diagnosis: A healthcare provider diagnoses a patient with a specific condition.
2. Treatment Plan: The provider develops a comprehensive treatment plan based on established clinical guidelines.
3. PLA Request: The provider submits a single authorization request to the payer that covers the entire treatment plan for a set period, often up to a year.
4. Review and Approval: The payer reviews the request against the patient’s diagnosis and care pathway. Upon approval, all services included in the plan are authorized.
5. Care Delivery: The patient receives necessary care without the need for repeated authorization requests for each service.

Key Benefits of Using Patient-Level Authorization

Implementing a PLA system offers substantial advantages for everyone involved in the healthcare journey.

• Faster Access to Care: Patients no longer have to wait for multiple approvals, which can be critical for conditions requiring timely intervention. Studies have shown that prior medical authorization can delay care for over 90% of patients. PLA cuts through this red tape.
• Reduced Administrative Burden: Providers and their staff spend countless hours on authorization paperwork. The American Medical Association (AMA) found that physicians and their staff spend nearly two full business days each week completing prior authorizations. PLA consolidates these tasks, freeing up valuable time to focus on patient care.
• Improved Patient Outcomes: By minimizing delays, PLA helps ensure that patients adhere to their treatment plans, which can lead to better health outcomes and a more positive patient experience.
• Greater Cost-Effectiveness: Streamlining the authorization process reduces administrative costs for both providers and payers. This efficiency can translate into overall savings for the healthcare system.

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When is Patient-Level Authorization Used?

PLA is particularly effective for managing chronic conditions or long-term treatment plans where the course of care is predictable. Common use cases include:

• Oncology treatments
• Chronic conditions like diabetes or heart disease
• Long-term physical therapy
• Behavioral health services

By applying PLA to these scenarios, healthcare systems can create a more predictable and seamless care experience.

Patient-Level Authorization vs. Prior Authorization

Challenges and Solutions in Implementing PLA

Despite its benefits, implementing PLA is not without challenges. Integrating PLA systems with existing electronic health records (EHRs) can be complex and requires significant IT investment. Payers and providers must also agree on standardized clinical pathways to ensure consistency.

However, solutions are emerging. Platforms like QPP MIPS are working to simplify this transition by offering integrated tools that facilitate communication between providers and payers. By investing in interoperable technology and fostering collaboration, the healthcare industry can overcome these hurdles and unlock the full potential of PLA.

The Evolving Landscape of Healthcare

Patient-Level Authorization represents a significant step forward in making healthcare more efficient, effective, and patient-friendly. By shifting the focus from transactions to treatments, PLA helps remove frustrating barriers to care and allows providers to dedicate more time to what matters most: their patients. As technology and collaboration continue to improve, PLA is poised to become a standard practice in modern healthcare delivery.

Ready to bring efficiency and speed to your authorization process? Get in touch with QPP MIPS to learn how we can help implement Patient-Level Authorization solutions tailored for your organization.