Your Prior Authorization Agent Works the Payers While You See Patients
The AgentWorks Prior Authorization Agent takes the payer forms, portal submissions, status checks and patient updates of prior authorization off your auth coordinator and the medical assistants who help them today. Your staff keep caring for the patients in the office; the agent works the payers and keeps every waiting patient informed.
What it takes off your plate
Here is how prior auth runs in most practices. A provider orders an MRI or a procedure. The auth coordinator pulls the clinical notes, finds the right form for that payer, fills it in, and submits it through one of several portals, each with its own login and rules. Then they wait.
Checking status means logging in again, payer by payer, or calling and holding. When a payer asks for more information, the request sits until someone notices. A peer-to-peer review is scheduled whenever the provider and the payer's reviewer can finally find a time.
Meanwhile, the patient waiting for a time-sensitive procedure calls the office to ask where things stand, and nobody at the front desk can say. It is the single biggest source of frustration in the practice, for staff and patients alike.
What the Prior Authorization Agent does, step by step
The work starts with the patient waiting on an answer, and continues into the payer paperwork.
- Tells the patient what happens next. When an order needs authorization, the Prior Authorization Agent texts or emails the patient that the request is being submitted, what it means and when they will hear next.
- Gathers the documentation. It pulls the visit notes, imaging, prior treatments and diagnosis codes the payer requires from the EHR, whether that is Epic, Athenahealth or Kareo, and lists anything missing for the provider.
- Completes the payer's form. It fills in the payer-specific form from the chart and attaches the supporting records.
- Submits through the right portal. It submits through the correct payer portal, including Availity where the payer uses it, and records the reference number.
- Checks status daily. It checks every open request each day and notes any change.
- Answers requests for more information. When a payer asks for additional records, it gathers them from the chart and resubmits, flagging the coordinator if a clinical answer is needed.
- Books the peer-to-peer early. When a request looks headed for denial, it contacts the payer to schedule the peer-to-peer and puts it on the provider's calendar with the case summary attached.
- Updates the patient. When the decision arrives, it tells the patient and, once approved, offers times to schedule the procedure.
Where the work is recorded
Every message to the patient and their replies land on the patient's record in the CRM your front desk already sees: what they were told, when, and any question they asked. When a patient calls, whoever answers sees the status and can give a real answer.
The authorization itself is recorded in the EHR and practice management system where your billing team works: the request, the documents submitted, the reference number, each status check, the payer's decision and the authorization number on the order. Nothing lives only in a portal.
The next morning, the auth coordinator sees which requests were submitted, which were approved or denied overnight, which payers asked for more information and which peer-to-peers are booked. The Prior Authorization Agent has already sent the patient updates each of those called for.
For the steps around authorization, see how an agent reclaims hours for patient care and how practices put their automation in the right order.
What your people do instead
Your auth coordinator handles the requests that need a person: the complex case, the appeal, the call with a payer that needs a clinician's voice. The rest of the day goes back to patients, explaining coverage to the family worried about a bill.
Medical assistants room patients and support providers instead of holding on payer phone lines. Providers walk into a peer-to-peer prepared, with the case summary in hand.
Patients waiting for care deserve to know where they stand. The AgentWorks Prior Authorization Agent keeps the forms, portals and updates moving so your staff can take care of them.
One next step
If prior authorization is where your practice loses the most staff time, take the free Industry Assessment. It shows which workflow an agent should take first. You can also see how agents support practices on the healthcare industry page.
See where the Prior Authorization Agent would start in your healthcare business.
I'm Dr. Mitchell, the Healthcare ambassador here. The free Industry Assessment reads your website and asks how calls, follow-ups and records happen today, then shows the first workflow worth handing to an agent like this one — and what your team gets back. Leave your email and I'll send the link.
Dr. Mitchell replies from healthcare@agentworksstudio.com. One email with the link — no list, no drip, unless you ask for the weekly letter. Or go straight there →