Patient Access Challenges in Healthcare

Patient access functions are a critical component of optimizing revenue cycle management (RCM) processes. While patient access teams have always faced operational hurdles, these challenges have grown more evident due to increasingly complex payer requirements, labor shortages, and more extensive administrative workloads. Effective workflows require the ability to follow financial clearance processes to track authorizations, verify eligibility and benefits, and identify at-risk accounts for immediate attention. Inefficiencies in these efforts are resulting in increased front-end denials, claim rework, and lost revenue, which can impact patient care, staff morale, and retention rates.

Key Patient Access Challenges and How Healthcare Organizations Can Address Them

1. Increased Administrative Burdens

   Patient access teams are increasingly overwhelmed by administrative tasks, such as prior authorizations and financial clearance processes. Front desk employees are spending more time on these tasks, leaving less time for patient-facing interactions. This shift not only affects patient care but also contributes to staff burnout and high turnover rates. The complexity of prior authorization requirements and overall volume of prior authorizations has grown significantly. Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024, an increase of 3 million over 2023 as Medicare Advantage enrollment has risen.

   How to Improve Administrative Workflows:

   Healthcare organizations can reduce administrative strain and staff burnout by modernizing workflows through automation and process standardization, allowing teams to focus more on patient interactions. Key improvement strategies include:

   • Automating eligibility verification and authorization status checks to reduce manual work.
   • Standardizing financial clearance workflows across scheduling, registration, and authorization teams.
   • Using centralized work queues to prioritize high-risk accounts requiring immediate attention.
   • Deploying automation tools that reduce repetitive administrative tasks for front-end staff.

2. Fragmented Workflows and Siloed Teams

   Decentralized patient access models have the potential to result in disconnected processes, creating barriers to efficient scheduling, eligibility verification, and prior authorization. These fragmented workflows lead to increased front-end denial rates, financial losses, and patient dissatisfaction. Studies show that nearly 50% of denials can be traced back to front-end revenue cycle issues, such as inconsistent processes that delay reimbursement and require extensive claims rework.

   How to Improve Workflow Centralization:

   Healthcare organizations can address fragmented workflows by creating a centralized operating model that aligns people, processes, and technology. Improvement strategies to reduce variability, strengthen financial clearance accuracy, and help prevent front-end errors that can lead to downstream denials include:

   • Centralizing scheduling, registration, eligibility verification, and authorization functions.
   • Establishing consistent policies and standardized workflows across departments and service lines.
   • Implementing unified governance and accountability for performance.
   • Using shared performance metrics to monitor registration accuracy and authorization completion.

3. Technology Gaps

   A reliance on outdated systems and manual processes and lack of advanced technology tools creates inefficiencies in patient access workflows. According to a recent AGS Health survey on the state of patient access, nearly half of the respondents indicated that no automation had been implemented to support patient access processes, while less than 10% had implemented automation for insurance eligibility and benefits verification.

   How Technology Modernization Improves Patient Access:

   Healthcare organizations can strengthen performance by modernizing technology infrastructure and introducing automation into front-end workflows. Key improvement strategies to reduce manual data entry, improve operational consistency, and help prevent front-end errors that delay reimbursement include:

   • Implementing automated eligibility and benefits verification tools.
   • Deploying prior authorization automation solutions to track payer requirements.
   • Integrating workflows with revenue cycle analytics platforms.
   • Replacing spreadsheet-driven processes with centralized workflow management tools.


4. Evolving Payer Requirements

   Frequent changes by payers to prior authorization rules result in rigorous documentation requirements, leading to incomplete or inconsistent documentation, compliance issues, and increased denial rates. Additionally, payers are using advanced technologies to automate medical necessity reviews, creating additional rework for hospital and health system staff when authorizations for procedures are denied. These issues are complicating the ability to streamline workflows and effectively manage staff time and resources, impacting eligibility and benefits verification, and prior authorizations.

   How Teams Can Navigate Changing Payer Requirements:

   Healthcare organizations can improve accuracy by implementing structured approaches to managing payer requirements and authorization workflows. Effective strategies to help reduce authorization errors, improve approval rates, and minimize administrative rework include:

   • Maintaining centralized payer rule libraries accessible to teams.
   • Using automation to track authorization requirements and status updates.
   • Aligning clinical documentation and coding teams with authorization workflows.
   • Providing ongoing staff education on payer documentation expectations.

5. Workforce Shortages

   The healthcare industry is facing a chronic shortage of skilled RCM professionals, including patient access staff. High turnover rates necessitate constant training and retraining of new team members, adding to operational inefficiencies. This shortage is compounded by the increasing administrative burden, leaving teams stretched thin and struggling to meet growing demands.

   How to Strengthen Workforce Capacity:

   Healthcare organizations can address staffing shortages by adopting scalable workforce models that combine internal teams with specialized support resources. Strategies to maintain operational continuity while alleviating pressure on staff include:

   • Implementing hybrid staffing models that incorporate global or near-shore support.
   • Using automation to reduce the volume of repetitive administrative work.
   • Standardizing workflows to simplify training and onboarding for new staff.
   • Expanding team capacity for high-volume activities such as eligibility verification and authorization management.

6. Lack of Analytics and Reporting Flexibility

   Inflexible analytics and reporting systems can hinder effective performance monitoring and root cause analysis. Many healthcare organizations lack the insights to identify and remediate systemic issues undermining patient access and financial clearance operations. Nearly 30% of survey respondents to the AGS Health survey on the state of patient access indicated that their current systems lacked the ability to drill down into trends, preventing organizations from identifying systemic issues and implementing targeted solutions.

   How Analytics Can Improve Performance:

   Advanced analytics and reporting tools help healthcare organizations identify the root causes of challenges and prioritize improvement initiatives. Key strategies to proactively address gaps before they impact reimbursement and patient experience include:

   • Tracking front-end denial rates and identifying the upstream causes of claim errors.
   • Monitoring registration accuracy and financial clearance completion rates.
   • Analyzing authorization turnaround times and approval rates by payer.
   • Using data insights to continuously refine patient access workflows and training programs.

Addressing these challenges requires a strategic approach that streamlines workflows, implements advanced analytics, and leverages automation tools to reduce revenue cycle operating costs. Download our white paper, "Transforming Patient Access: A Practical Guide to Maturity," for a detailed roadmap and actionable strategies to overcome patient access challenges and optimize your revenue cycle management. Stay tuned for our next article in the series that shares a stepwise approach to centralization for patient access.