According to a 2018 American Medical Association survey, most doctors report that it takes between one and five days after requesting prior authorization to get the approval needed to move forward with what are often critical diagnostic or therapeutic interventions for patients.
Getting prior authorization for a patientโs medical services or treatment has long been a cause of frustration for patients, providers โ and even payers alike. While providers insist itโs an unnecessary process that often leads to delays in care, payers maintain that itโs an important process for ensuring quality and value in healthcare โ both critical elements in the imminent shift to value-based care.
Fortunately, experts from across the country are working to identify a happy medium between the administrative burden and the benefits that getting a prior authorization provides. As part of its Patients Over Paperwork initiative, The Centers for Medicare and Medicaid Services (CMS) is looking for answers. As such, theyโre currently evaluating more than 2,600 comments from healthcare professionals about how the process could be improved. While the agency doesnโt anticipate prior authorization going away, it could be modified in certain instances such as when durable medical equipment is needed after certain outpatient procedures, for example.
Automating the Process
Automation is helping industries everywhere save time and reduce operational expenses and healthcare is no exception. Physician advocates wonder why this largely manual process for prior authorizations couldnโt somehow be automated? Current processes often include archaically sending faxes and/or PDFs, toggling back and forth between payer web portals, making phone calls, etc. Experts estimate automating prior authorization could save more than $400 million per year โ and automation has been put into place for similar processes such as verifying a patientโs benefits. Problems such as regulatory concerns and interoperability between electronic medical record (EMR) systems and administrative systems donโt currently allow for this, but federal agencies, EMR vendors and healthcare providers are looking to break down such barriers.
A project known as โThe Da Vinci Project,โ which is a collaboration between healthcare industry and federal agencies aims to reduce the administrative burden on providers โ including enhancing workflows related to prior authorization. Fast Healthcare Interoperability Resources (FHIR) hopes to employ a B2B process using existing IT infrastructure resources to allow providers to request prior authorization at the point of service and receive immediate authorization when appropriate. This work will tackle regulatory concerns related to HIPAA compliance in an effort to streamline the process.
Other organizations such as Epic Systems and Humana are working together to test other potential solutions such as using Epic to allow insurers to exchange data automatically โ which could provide the clinical data needed for payers to provide faster authorization. Another trade organization โ Americaโs Health Insurance Plans is in the testing phase for another automated tool that could scale to automate prior authorization processes.
While these options could certainly provide a great deal of relief for providers, some argue that itโs still unnecessary โ since the vast majority of requests for prior authorization are granted. Other providers still are hoping that those who demonstrate adherence to value-based care standards (such as those who participate in ACOs or value-based contracting) could avoid the hurdle altogether.
Either way, with multiple options being developed, evaluated and tested โ itโs only a matter of time before we see some level of automation in the prior authorization process.
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