Internal Authorization, External Impact: A Case Management Innovation to Reduce Length of Stay and Improve Throughput
BY , DNP, RN, CCM, CMAC, CMGT-BC, CMCN, ACM-RN, FCM, FAACM
Delays in payer authorization for post-acute services remain one of the most persistent—and often underappreciated—drivers of prolonged hospital length of stay (LOS). While clinical teams may achieve medical readiness for discharge, patients frequently remain hospitalized due to administrative barriers outside of direct clinical control. At University of Illinois Health (UIH), this challenge was both visible and measurable, prompting a targeted intervention led by case management to address inefficiencies in the prior authorization (PA) process. The results demonstrate how rethinking workflow ownership can meaningfully improve patient flow, reduce avoidable days, and generate substantial cost savings while enhancing the overall patient journey.
Historically, UIH followed a common industry model in which post-acute providers—such as skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs)—were responsible for initiating prior authorization requests. This approach introduced inherent delays, as these external partners were subject to payer turnaround times typically averaging 96-108 hours (4+ days). Internal data revealed that these delays contributed significantly to excess hospital days, with 1,608 avoidable days in FY2024 attributed to payer authorization delays. At a conservative estimated cost of $2,000 per inpatient day, this translated to approximately $3.2 million in annual financial impact, underscoring the urgency of addressing this inefficiency.
Recognizing the opportunity to intervene, UIH implemented a redesigned workflow in February 2025 by bringing the prior authorization process in-house, inspired by the work of Adria Grillo-Peck at Indiana University Health, featured in CareManagement Journal in December 2022. This change centered on the creation of a dedicated Prior Authorization Specialist role embedded within the case management team. Two specialists were hired to proactively initiate and manage authorization requests for post-acute services, working in close collaboration with case manager nurses and social workers. This shift transformed the process from a reactive, externally dependent model into a proactive, internally controlled workflow. By aligning authorization initiation with real-time clinical progress and discharge planning activities, the team was able to significantly reduce delays and improve coordination across the continuum of care.
The impact of this intervention is best understood through both operational and outcome data. From February 2025 through March 2026, the volume of authorization requests increased substantially, reflecting both program adoption and scalability. Monthly case volume grew from 24 cases in the first month of implementation to over 100 cases in multiple months, including 109 cases in March 2026. Despite this increase, approval rates remained consistently strong, generally ranging between 80% and 85%. Denials, while present, remained relatively stable, suggesting that the internal model improved efficiency without negatively impacting payer decision-making.
Perhaps the most compelling outcome is the reduction in avoidable days attributed to payer delays. By FY2026, avoidable days related to prior authorization decreased to 668, representing a substantial improvement from the FY2024 baseline of 1,608 days. This reduction of nearly 60% reflects the effectiveness of internalizing the authorization process and demonstrates the direct impact of case management—driven operational redesign on hospital throughput and efficiency.
Turnaround time (TAT) for authorization approvals also improved dramatically. Prior to the intervention, payer TAT averaged approximately 108 hours. Following implementation, TAT consistently decreased to a range of approximately 18 to 28 hours, with sustained performance through March 2026 and an overall project average turnaround time of 23.08 hours. This shift allows discharge planning to proceed in parallel with clinical care rather than being delayed by administrative processes, fundamentally changing the pace at which patients could transition to the next level of care.
Equally important is how quickly patients were discharged after authorization was obtained. The data demonstrates that a substantial proportion of patients were discharged within one day of authorization approval, with combined Day 0 and Day 1 discharge rates frequently reaching 40% to 60%. This indicates that once the administrative barrier was removed, the system was largely able to execute timely transitions of care. However, variability remains, with some patients experiencing delays beyond three or four days. These findings reinforce that while prior authorization is a major barrier, it exists within a broader ecosystem that includes post-acute bed availability, transportation logistics, patient readiness, and interdisciplinary coordination.
One of the most meaningful secondary outcomes of the intervention was the ability to secure authorization in advance of medical readiness for discharge. Early in the program, nearly half of patients had authorization in hand at least two days prior to discharge readiness, with peak performance exceeding 50%. While this metric fluctuated over time, it highlights the potential for proactive authorization workflows to eliminate discharge delays altogether when aligned effectively with anticipated discharge dates.
From a case management perspective, this initiative reinforces the importance of controlling key workflow elements that directly impact patient outcomes and operational efficiency. By internalizing the prior authorization process, case management teams can exert greater influence over discharge timelines and reduce reliance on external variables. At the same time, the findings emphasize that throughput is inherently multidisciplinary, requiring alignment across clinical, operational, and post-acute partners to achieve optimal results.
The introduction of the Prior Authorization Specialist role also highlights the value of role optimization within case management. By assigning authorization responsibilities to dedicated specialists, case manager nurses and social workers are able to focus on higher-level clinical decision-making, patient engagement, and complex discharge planning. This supports both efficiency and staff satisfaction, enabling team members to practice at the top of their license while improving overall workflow performance.
The financial impact of this intervention is both measurable and compelling. Based on the reduction in avoidable days—from 1,608 in FY2024 to 668 in FY2026—the organization avoided approximately 940 inpatient days annually. At an estimated cost of $2,000 per day, this equates to approximately $1.88 million in direct cost avoidance. With an estimated annual cost of $180,000 for two Prior Authorization Specialists, the program yields a net financial benefit of approximately $1.7 million, representing an ROI exceeding 900%. Importantly, this calculation reflects only direct cost avoidance and does not account for additional gains associated with improved throughput, increased admission capacity, enhanced staff efficiency, or performance in value-based care models. When these factors are considered, the true financial and operational impact of the program is likely substantially greater.
Looking ahead, the data suggests several opportunities for continued refinement of the model. Earlier initiation triggers for authorization requests, enhanced integration with estimated discharge date (EDD) workflows, and targeted payer engagement strategies may further improve performance.
The UIH experience demonstrates that a focused, case management—driven operational redesign can produce significant improvements in both patient care and health system performance. By bringing prior authorization in-house, UIH not only reduced turnaround times and avoidable days but also strengthened its ability to deliver timely, efficient, and patient-centered transitions of care. For case management leaders seeking practical strategies to improve throughput and reduce LOS, this model offers a compelling and replicable solution—one that reinforces the critical role of case management in shaping the future of healthcare delivery. Thank you to Adria Grillo-Peck and the IU Health team for publishing their work to inspire others!
References
Dashnaw, E., Grillo-Peck, A., Greisl, N., Burke, K and Altenberger, E. (2022). Reducing hospital length of stay by expediting precertification. CareManagement, Dec 2022, 9-15.
Dr. Colleen Morley, DNP, RN, CCM, CMAC, CMGT-BC, CMCN, ACM-RN, FCM, FAACM, is an accomplished nurse leader and nationally recognized expert in case management, readmission reduction strategies and care transitions. She serves as Associate Chief Clinical Operations Officer for Continuum of Care at UI Health and is a Past National President of CMSA. A published author and educator, she has received multiple awards for her advocacy and leadership. With more than 25 years of nursing experience, Dr. Morley is dedicated to advancing the profession through mentorship, policy reform, and strategic innovation in care coordination, utilization management, and patient outcomes across the healthcare continuum.
