Widespread Electronic Prior Authorization Standards — Getting Closer?

While electronic prior authorization standards are a great idea, in theory, they have been much more illusory in practice. Insurance payers have developed their processes independently and have been reluctant to change or adapt system-wide to make the overall prior authorization process less cumbersome and more streamlined.

Developing over decades, utilization review, and prior authorization have become a trusted technique that insurance companies employ to manage care. But although intended to review physicians’ decisions and guard against unnecessary treatment, it has evolved into a cost-containment strategy that runs counter to the improvements being made in diagnostics and care delivery.

Calls for Change and Improvement

2011

In 2011, the American Medical Association (AMA) issued a white paper calling for standardization of the prior authorization process. At that time, the association called for replacing manual prior authorization processes with automated ones that were “transparent, unambiguous” and conducted in real-time.

2014

In 2014, an article in the trade newsletter HIMSSwire touted the promise of electronic prior authorizations, saying that industry-wide adoption based on national standards held “the potential to streamline and improve the process for all stakeholders, improving process efficiencies and reducing time to treatment.”

HIMSS further stated that electronic prior authorizations could “potentially result in fewer prior authorization requests because healthcare providers will have the coverage information they need when making a treatment decision.”

2018

In 2018, the AMA, working with multiple groups and associations, including the American Hospital Association, the Medical Group Management Association, and Blue Cross-Blue Shield, issued a Consensus Statement on Improving the Prior Authorization Process urging healthcare leaders and policymakers to act urgently to improve the prior authorization process that has become onerous for physicians.

The statement encouraged “health care providers, health systems, health plans, and pharmacy benefit managers to accelerate the use of existing national standard transactions for electronic prior authorization,” to speed up drug authorization approvals and improve medication adherence.

2019

The AMA, along with 50 or more healthcare associations and groups, issued the “Prior Authorization and Utilization Management Reform Principles,” and issued their findings on their survey of 1,000 physicians that found that 91% of respondents reported care delays due to prior authorization requirements.

Additionally, the AMA joined with 100+ organizations to urge comprehensive reform in a letter to Seema Verma, Administrator, Centers for Medicare & Medicaid Services, dated September 20, 2019.

Finally, Being Heard

In 2019, Representative Susan DelBene (D-WA) initiated a bill in the House of Representatives through the Ways and Means Committee — H.R. 3107, the Improving Seniors’ Timely Access to Care Act. This bill is meant to streamline and standardize the prior authorization process through Medicare, the first step in implementing meaningful change.

While the American Healthcare Insurance Plans (AHIP) group has signed on to support all of the initiatives, insurance payers have been clear that prior authorizations are seen as an effective tool that helps contain costs and manage the care being delivered, and the industry has seen the use of prior authorizations increase, not decrease. According to the Medical Group Management Association (MGMA), 90% of healthcare leaders report that payer prior authorization requirements are increasing with no end in sight.

How Electronic Prior Authorizations Look Today

Cloud-based, electronic prior authorizations are accomplished using automation and AI-driven software that can be integrated bi-directionally with a hospital or practice’s EHR/EMR, and billing system. As soon as a patient’s order is input, tests or medications requiring prior authorizations can be electronically identified, provider/facility, patient demographics, and test/diagnosis details entered, the information can be collected, and an approval request is initiated in real-time to the insurance payer portal.

AI-driven software with machine learning capabilities would access continually updated insurance information clearinghouses storing thousands of insurance groups and plans, each with their unique guidelines and requirements, and electronically determine the prior authorization parameters for routing the request.

Here some of the benefits that could be recognized:

  1. Initial Processing — From the moment patient information is entered into the EHR/EMR system; guided processes are monitored for the key identifiers to initiate prior authorization approval. Matching ordered tests or medications with constantly updating insurance preauthorization requirements, the system stands ready to gather the required information and submit the request in real-time.

  2. Continual Follow-Up — Once the prior authorization approval is submitted, electronic follow-up occurs 24/7 until a final resolution is obtained. If additional information is required or an appeal is necessary, the practice is notified immediately so that a response could be crafted and submitted as soon as possible.

  3. Dashboard Notifications — Waiting for insurance payer responses has historically been a time-consuming affair that took hours of follow-up and burdensome administrative effort. With an interactive dashboard, today’s automation and AI-driven software give a complete snapshot and clarity on all active prior authorization requests so that patient and clinician questions can be answered immediately and follow-up can occur as necessary.

  4. Scheduling — Alleviating the frustrations of having to schedule and reschedule patients based on prior authorizations, there are more accurate parameters allowing a more efficient process for everyone. This allows for an improved patient experience.

  5. A/R and Claims Management — With fewer prior authorization problems comes less rejected or denied claims, and more revenue allowed to hit the bottom line.

  6. Analytics and Reporting — Bringing full transparency to future operations, timely analytics, and reporting can pinpoint breakdowns in efficiency or areas needing improvement.

As reliance on automation continues to grow, differentiating from others by offering pristine business support to referring providers or self-referral patients helps in securing future potential patient growth. Your practice will see the benefit to their patients with more timely care initiation and less cumbersome reimbursement.

While there has been growing discord about prior authorizations for several years with major governmental and industry-representative bodies joining the chorus, little has changed. Even if foundational improvements are considered, the prior authorization process will likely continue in a new form but still, require clinician and administrative time to manage. Being proactive to facilitate an efficient process seems to be the best solution.

Contact Infinx to schedule a demonstration and learn more about the efficiencies gained through adopting an automated prior authorization solution.

About the Author

Infinx
Infinx Healthcare provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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