Streamlined Prior Authorization Workflow for MAC Operations

Digital Blue helps MAC with prior auth requests by enhancing front-end features, automating workflows, and optimizing processes.


Prior Authorization (PA) is a valuable, necessary process for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers. Having reduced spending on these claims by $ 1 billion-$2 billion, prior authorization has become the standard operational process for Medicare claims, and the requirement has no set end date.  Timely and efficient processing of DMEPOS claims is essential to patient outcomes and satisfaction and meeting the performance standards for MAC contracts. Payers are optimizing their PA workflow solutions and systems to keep up with rising Prior Authorization volume, complexity, and processing costs. 

About the Client

The client is a Medicare Administrative Contractor (MAC) for the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare. MACs are private healthcare insurers awarded jurisdiction based on geographical area to process Medicare Part A, Part B, or Durable Medical Equipment (DME) claims.  The client serves over 24 million Medicare beneficiaries and 100,000 healthcare professionals. To accommodate high demand and facilitate a streamlined PA workflow solution, the client partnered with Digital Blue. 

“The client desired an assessment of their current PA process to determine the best course forward to efficiently scale, operate, and adapt PA operations for handling growing PA request volume and processing complexity while lowering operating costs.” 

Solution Highlights

The client was experiencing volume spikes from the periodic expansion of prior authorization requirements to additional codes and programs. Over the last 3-year period, every new introduction required a long lead time for the client to make system changes and ramp up staffing to meet the increased processing volume and complexity. At the time, Power Mobility Device (PMD) and Pressure Reducing Support Surfaces (PRSS) PA programs were the only two requiring Prior Authorization. They were also concerned about scaling up the staff and making necessary system changes to meet requirement timelines. Digital Blue provided a data-driven solution outline providing substantial opportunities for improvement to free capacity, lower cost-per-case, and increase transparency in the manually intensive PA process.

Digital Blue applied its blueprint approach to the client’s business processes streamlining its Prior Authorization process with the implementation of a fully integrated, optimal, and truly assistive technical solution utilizing the existing technology stack by focusing on the following areas for optimization:

Enhanced Front-End Features

Minimal front-end features hindered optimal case filtering and information capture—Digital Blue  Enhanced front-end supplier experience for improved PA request intake. A smart business form was introduced with built-in critical data aggregation and business rules to significantly assist with validating incoming requests to ensure valid requests are routed for clinical review. In clinical review, they integrated medical necessity checklists to drive the determination and automate downstream correspondence generation for PA request decisions.

Automated and Integrated Workflows

Low automation level causing significant human dependency for guidance on work

routing, content storage, reporting & work management. Disjointed systems resulting in inefficient skilled resource usage for duplicative data entry, cross-system data comparison, and data aggregation

Digital Blue Automated data extraction, aggregation, posting & non-clinical validation with shared-system integrations. Process optimized workflows housing and executing procedure and business rules. 

Improved Flexibility, Insights, and transparency

The Client’s current system lacked a transparent view of the existing technology’s workload, process, and utilization. Integrating reporting tools and business dashboards would provide better insights and transparency, meaning fewer manual steps for the reporting process. Through automation, clinical information could be presented and extracted more contextually with improved review performance. 

Overall Results

The final solution helped the client minimize risk and financial loss related to capacity shortages and volume spikes and resulted in production improvements between 125%-200% for clinician processing of PMD and PRSS PA and administrative production improvements saving 33-53 hrs/year per FTE.  

Key measurable outcomes of these improvements include:

  • Estimated capacity increase of 9,302-11,468 hours/year
  • Cost savings of $ 475,000-$590,000/year
  • Improved supplier experience
  • Free up clinician capacity for higher-value work
  • Process and operational insights made readily available
  • Improved resilience for incorporating new programs and/or codes
  • Reduced susceptibility to human error
  • Increased transparency to suppliers

Optimize MAC Operations by Partnering with Digital Blue

The Digital Blue team has been optimizing MAC operations since 2006. Our experienced team has helped several MACs make significant, measurable improvements in their business performance. Schedule your exploratory digital transformation call today