Insurance/Medicare Pre Authorisation Workflow
Automatically extract patient insurance details and procedure codes, assemble clinical documentation, submit preauthorisation requests to health funds, and track approval status so your billing team only steps in when something needs a human decision.
The Problem
Prior authorisation is the tax your practice pays before it can deliver care. Every scheduled procedure triggers the same grind: pull the patient's insurance details, find the right health fund portal, assemble clinical documentation, submit, wait, chase. Your admin staff does this 43 times per physician per week.
That's not a typo. Forty three requests, every week, for every doctor in the building. Across the whole practice, PA processing eats 34 hours of staff time per physician per week when you factor in the phone holds, the portal navigation, the faxing, and the resubmissions after denials.
Each individual case averages over 20 minutes of hands on work. Multiply that across a full clinic schedule and your billing team is spending more time getting permission to treat patients than supporting the people who actually treat them. And the worst part? Health funds themselves acknowledge that 40 to 60 percent of these requests could be auto approved. The paperwork exists because the systems haven't caught up.
Staff turnover in medical admin is directly tied to this. People don't leave because the pay is bad. They leave because they spent three hours on hold with a insurer, got disconnected, and had to start again. The burnout is real, and it's expensive to replace.
How It Works
A workflow built in Make or Power Automate connects your practice management system to health fund portals and your billing team's dashboard. Here's the sequence.
1. Procedure scheduled in your PMS
When a clinician books a procedure that requires pre authorisation, the workflow triggers automatically. It pulls the patient's insurance details, the relevant procedure codes (MBS item numbers), and the referring provider information straight from your practice management system.
2. Eligibility check
The workflow queries the insurer's API or portal to confirm the patient's coverage is active and the procedure falls under their plan. If there's a coverage gap or the policy has lapsed, your billing team gets an immediate alert before anyone wastes time assembling documents.
3. Clinical documentation assembly
Based on the procedure code and insurer requirements, the workflow pulls the required clinical notes, diagnostic results, and supporting documentation from your records system. It assembles these into a formatted submission packet that matches what the specific insurer expects.
4. Pre authorisation submission
The completed packet is submitted electronically to the insurer. For health funds with API access, this happens directly. For those still using portal submissions, the workflow handles the form entry. The submission reference number is logged automatically.
5. Status monitoring
The workflow polls the insurer's system on a schedule you set. It checks whether the authorisation has been approved, denied, or whether additional information has been requested. No one on your team needs to remember to follow up.
6. Team notification and next steps
When a decision comes back, your billing team gets an alert in Slack or Microsoft Teams. Approvals are logged and the procedure is cleared to proceed. If the insurer requests more information, the workflow pre assembles the response materials so your team can review and send rather than start from scratch.
Why Portals and Phone Calls Don't Scale
Most practices have adapted to PA by throwing people at it. One more billing coordinator. A dedicated PA person. Maybe a virtual assistant service at $12 an hour. These solutions work until they don't.
The core issue isn't effort. It's fragmentation. A five physician practice might deal with 15 different health funds, each with its own portal, its own document requirements, its own turnaround times. Your PA coordinator has 15 browser tabs open, a spreadsheet tracking where each request sits, and a phone wedged between their shoulder and ear. That's not a workflow. That's a memory test.
A single denied PA for a scheduled knee replacement doesn't just delay the patient's surgery. It delays the $15,000 in revenue attached to it. And the denial often comes down to a missing document that nobody realised was required by that specific insurer for that specific code.
Automation doesn't replace clinical judgement. It replaces the data entry, the portal navigation, the document gathering, and the status checking. The 60 percent of PAs that are routine and predictable get processed without anyone touching them. Your team focuses on the 40 percent that actually need a human brain.
The Regulatory Tailwind
Regulatory guidelines mandate that impacted health funds must offer FHIR based electronic PA submission APIs by January 2027. This matters for two reasons.
First, it standardises how PA requests are submitted and tracked electronically. Instead of navigating 15 different health fund portals, your automation connects to a standardised API. Second, the rule requires faster decision timelines from health funds. Urgent requests must be processed within 72 hours; standard requests within seven calendar days.
Gold card laws are expanding too. certain jurisdictions already allow providers with high approval rates to bypass PA for certain services. More states are following. Practices that track their approval rates now (which an automated system does by default) will be first in line when these laws reach their jurisdiction.
The practices that build PA automation today aren't just solving a current problem. They're building the infrastructure that plugs directly into the regulatory changes coming in the next 18 months.
The Business Impact
Take a four physician practice with two billing coordinators handling PA. Each physician generates 43 PAs per week. At 20 minutes per case, that's roughly 57 hours of PA work per week across the practice. Your two billing coordinators are spending most of their time on authorisations alone.
Automating the routine 60 percent cuts that to roughly 23 hours per week of manual PA work. That's 34 hours recovered. At a billing coordinator's loaded cost of $35 per hour, you're saving $1,190 per week. Over a year, that's $61,880 in recovered staff capacity.
But the bigger number is the revenue acceleration. Every PA that sits in limbo is a procedure that can't be billed. If automation shaves an average of three days off your PA turnaround, and your practice schedules 170 procedures per week that require authorisation, you're pulling forward tens of thousands in receivables that previously sat waiting for insurer approval.
Then there's the denial rate. Incomplete submissions are the leading cause of PA denials. An automated system that assembles documentation based on each insurer's specific requirements doesn't forget to attach the clinical notes. Fewer denials means fewer resubmissions, fewer delayed procedures, and less revenue leakage.
- 34 hours of staff time recovered per week in a four physician practice
- Over $61,000 in annual savings from reduced manual PA processing
- Faster procedure scheduling with automated eligibility checks before submission
- Lower denial rates through consistent, insurer specific documentation assembly
- Real time PA status visibility for your entire billing team without portal logins
- Automatic audit trail of every submission, response, and approval for compliance
Frequently Asked Questions
Every insurer has different requirements. How does automation handle that?
The workflow is configured with insurer specific rules for document requirements, submission formats, and portal access methods. You build these once per insurer, and the system applies them automatically based on the patient's insurance. When a new insurer requirement changes, you update one rule rather than retraining your entire team.
Does this work with our existing practice management system?
Make and Power Automate integrate with most major PMS platforms including those that support HL7 FHIR. If your PMS has an API or exports data in standard formats, the workflow can pull from it. For systems without APIs, RPA tools can bridge the gap by interacting with the software interface directly.
What about health funds that still require fax or phone submissions?
The automation still handles document assembly and pre population for these cases. Your staff gets a completed submission packet ready to fax or reference during a phone call, cutting a 20 minute task down to two or three minutes. As health funds adopt electronic submission (mandated by 2027), these manual steps phase out naturally.
Do we really need this if we only have a few physicians?
A solo physician practice still processes over 40 PAs per week. That's 13 plus hours of staff time. For a small practice, that might be the difference between needing one billing coordinator or two. The maths scales down just as well as it scales up.
What happens when a PA is denied?
The workflow flags the denial immediately, captures the denial reason code, and pre assembles the appeal documentation based on that reason. Your team reviews and submits the appeal rather than starting the entire process from scratch. The system also tracks denial patterns so you can identify which health funds and procedure codes have the highest denial rates.
Is this compliant with healthcare privacy regulations?
The workflow is built within your existing infrastructure and uses the same security controls as your practice management system. Patient data moves between systems you already trust. For cloud based orchestration tools like Make, you configure the workflow to process only the minimum necessary data elements required for the PA submission.
How long does setup take?
A basic PA automation covering your top five health funds by volume takes two to three weeks to configure and test. Most practices see measurable time savings within the first month. Complex setups with 15 or more health funds and multiple procedure categories may take longer, but each additional insurer is incremental work, not a rebuild. Book your free audit and we'll map your current PA volume and insurer mix to estimate the impact.
Sources
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