Using Technology to Transform Prior Authorization

Prior authorization is the process providers use to request pre-approval by health plans for health services payment for their patients. Like other areas of healthcare, prior authorization is entering a new era of technology transformation.

There is a new national focus on using technology to ease the provider burden of the prior authorization/utilization management process. For decades, prior authorization has been a primary source of division between health plans and provider communities. There are several technology initiatives underway to ease the prior authorization time and cost burdens for providers.

The American Medical Association (AMA) believes in reducing the overall volume of medical services and medications requiring prior authorization, according to HealthCareDive report. The AMA also wants to reduce the provider’s administrative burden through the adoption of standardized, automated processes. The AMA is also advocating for more transparency around utilization management clinical criteria and evidence-based guidelines used in making prior authorization decisions.

Currently, the AMA has an advocacy campaign and a legislative grassroots effort addressing the prior authorization process. The Stories section is particularly effective as it includes anonymous, at times, heart-wrenching stories submitted by patients and providers documenting prior authorization delays and how these affected patients receiving “the care they need.” In 2017, the AMA and coalition of 16 healthcare organizations developed the Prior Authorization Consensus Reform principles (Prior Authorization Consensus Statement), focused on avoiding administrative waste and delays in patient care. There are also a growing number of states with proposed legislation to change prior authorization and utilization management.

Quality improvements

The eHealth Initiative and Foundation (eHI) is a Washington D.C.-based, non-profit (independent) organization whose mission is to drive patient quality improvements through innovative healthcare information technology. During last years’ annual conference, eHI decided to begin a prior authorization initiative consisting of multi-stakeholders to establish a set of recommended practices to improve the current prior authorization environment.

Among other groups, industry participants in the collaborative included: America’s Health Insurance Plans (AHIP), (AMA, Delaware Health Information Network (DHIN), Health Level Seven International (HL7), Office of the National Coordinator for Health Information Technology (ONC), Workgroup for Electronic Data Interchange (WEDI), and several health plans from across the country.

Beginning in mid-2018, eHI interviewed industry experts and had a series of industry round-table discussions. Early in 2019, based on information collected in their industry interview and round-table discussions, eHI released two white papers: Prior Authorization: Current State, Challenges and Potential Solutions and Considerations for Improving Prior Authorization. eHI also hosted a webinar on the topic Webinar: Considerations for Improving Prior Authorization which provides background on using  technology to meet the need of prior authorization and utilization management. Below are excerpts from eHealth Initiative’s industry coalition publications and HighPoint Solutions’ recommendations for health plans:   

  • Transparency of payer policy and evidence-based clinical guidelines at the point of care – Making these available at the point of care, such as in EHRs, the availability of eligibility, benefits coverage, clinical guidelines, payer documentation requirements, and patient financial responsibility.
    HighPoint Recommendations for Health Plans
      • For large provider groups, consider education sessions on evidence-based guidelines (MCG, InterQual, and internal Medical Policies) for high volume procedures and/or procedures with high denial rates (i.e., medical, pharmacy, and radiology).  Place links to your internal Medical Policies and other evidenced-based guidelines on your Prior Authorization/UM Provider Portal. 
  • Reducing the overall volume of services and drugs requiring prior authorization – Evaluate the need for prior authorizations or reduce the frequency for:
    • Patients who are taking medications chronically, or clinically unstable and undergoing repeat procedures
    • Medications and procedures with low denial rates.
    • Gold Carding eliminating or relaxing prior authorization requirements for providers with successful track records, or healthcare professionals who are participating in risk-based payment contracts.HighPoint Recommendations for Health Plans:

      • During an annual review of your Prior Authorization List, consider the earlier suggestions including ‘gold carding’ for provider groups with risk-based or value-based contracts.
  • Developing alternative payment models – payment models that promote bundled authorization for procedures, medications, and Durable Medical Equipment associated with a particular episode of care. An example would be bundled authorizations to acknowledge the most frequent components of care associated with an episode, rather than asking healthcare professionals to request authorization for each individual procedure, medication, or durable equipment.HighPoint Recommendations for Health Plans:

    • For risk-based or value-based contract arrangements, consider bundled authorization/ payment arrangements that would require a single authorization. Bundled payments may work best when used with Centers of Excellence, identifying providers that perform interventions at the highest quality and cost.

Here are other prior authorization technology initiatives addressed in the eHI publications: 

Smart Prior Authorization (SPA)

This is a solution that specifically addresses the five areas of opportunity for improvement as outlined in the Consensus Statement. This is a state of Delaware prior authorization pilot program in collaboration with the Medical Society of Delaware and Delaware’s Health Information Network (DHIN).

CMS Documentation Requirement Lookup Service:
CMS is collaborating with the P2 FHIR® Task Force and the Da Vinci Project (a HL7 initiative) as part of the CMS Documentation Requirement Lookup Service Initiative. The initiative streamlines workflow access to Medicare requirements. The task force will help CMS identify and solve infrastructure barriers that could prevent providers’ use of the Medicare Fee-For-Service (FFS) Documentation Requirement Lookup Service on a wide scale.

HighPoint Solutions

eHI will continue to monitor technology to assist with transforming the prior authorization process and provide support to the healthcare industry to improve clinical outcomes for patients. HighPoint Solutions will continue to provide blog updates on how these technological solutions are breaking the mold of the prior authorization and utilization management.

To learn more about the HighPoint Population Health practice and what we can do to help organization seeking a new population health vendor, please reach out to Chris McShanag, vice president, population health.