Automating Prior Authorization Workflows for a Leading Healthcare Enterprise

Executive Summary

A leading healthcare enterprise managing large-scale pharmacy benefit and specialty care operations needed to reduce the manual effort involved in Prior Authorization workflows. Each PA request required clinical review, payer-specific form completion, evidence validation, and citation-backed decisioning, creating delays across approval and rejection cycles.

Factspan developed an AI-assisted PA Automation solution that used patient Electronic Health Record data to generate answers for PA form questions, validate response quality, assign confidence levels, and provide rationale-backed evidence for human review. The pilot reduced PA task completion time from multi-day cycles to approximately 3 hours, creating a scalable foundation for broader authorization automation across drugs, payors, and PBM workflows.

Business Impact:

• Reduced PA task completion time from 1 to 10 days to approximately 3 hours
• Supported automation for 10 drugs in the pilot scope
• Enabled controlled rollout for 10 Benefit Verification Representatives
• Addressed workflows involving 150 to 1,000 questions per PA request
• Created a scale path for automation across 1.2M annual PA requests
• Identified potential annual savings of up to $3M