Since the 1960s, medical prior authorizations have established a system of checks and balances that help control the costs of medication, services, and procedures. While much has changed since those days, many challenges—such as cumbersome manual processes for payers and providers and delays in care for patients—have remained the same.
Discussions on how to improve the prior authorization (PA) process continue and controversy around proposed legislation persists, but there’s also good news. We have the technology today to create an end-to-end, electronic PA (ePA) solution that automates manual processes, operates in near-real time, integrates into electronic health record (EHR) systems, and automatically syncs with PA rule changes.
New Standards and Solutions Solve Long-Standing Problems
The Centers for Medicare & Medicaid Services (CMS) last January issued its final rule on Reducing Provider and Patient Burden by Improving PA Processes. The rule requires payers to make application programming interfaces (APIs) available to share PA requirements, status, and final decisions with patients and providers by early 2023.
While the timeline of the CMS rule continues to be debated in health plan circles, fully compliant technology is available today to reduce PA effort, complexity, and cost by advancing safe and secure electronic communications between administrative and clinical information systems.
It’s possible due to the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard. FHIR enables new technology solutions to connect medical record vendors (regardless of a physician’s specialty or EHR) to payer database APIs and share benefits between health plans and their networks in near-real time, regardless of the software being used.
Instead of disjointed workflows and time-intensive manual tasks, physicians using EHRs that partner with integrators or connect directly to payers can immediately view patient eligibility and submit prior authorizations with attached medical records at the time of care.
Save Time, Save Money, Save Lives
Process improvements aren’t the only benefits. The nonprofit Council for Affordable Quality Healthcare (CAQH) found in its 2020 index report that both payers and providers would profit from ePA. By replacing a manual system of phone calls and faxes with an automated electronic process, the industry avoided spending $482 million in 2020, and could save an additional $417 million annually if plans and providers fully convert to electronic transactions.
Patients would profit too. Consider that 94% of physicians said the medical PA process delays patients’ access to necessary care in a recent survey by the American Medical Association, and 30% said prior authorizations have led to a serious adverse event for a patient in their care. While those numbers are striking, they aren’t surprising when you consider the changing nature of reimbursement models and the unique systems each stakeholder currently uses to store information.
Better PA Is Possible Today
Healthcare payers are already adopting integrated systems which enables them to deliver:
- A member’s full eligibility profile, including unmet deductible and patient co-pay
- Requirements indicating whether PA is needed, and if so, its conditional settings and medical records, helping avoid healthcare delays
- Recent member health history, including treatment details from claim events, presented in an intuitive format consistent with the provider’s EHR
- A range of out-of-pocket cost for any covered benefit
- Expedited referrals to in-network specialists, labs and imaging facilities that take into consideration cost, outcomes, and proximity
While the new administration may pivot on PA policy, industry leaders project demand for these tools to explode as process efficiencies translate to better healthcare at a lower cost. Act now to begin replacing legacy methods with new solutions, and by 2023 you will not only be compliant but also will be well-positioned to expedite PAs and help providers accelerate care.
This article was originally published on the DrFirst blog and is republished here with permission.