Four health systems are now using real-time prior authorization checks embedded in the Epic electronic health record, tackling a major pain point for providers.
The electronic health record giant collaborated with insurers UnitedHealthcare, Network Health and Aetna to set up the electronic workflows to modernize the manual and time-consuming prior auth process.
Epic launched real-time insurance reviews directly into EHR workflows using an industry-standard application programming interface (API) called Coverage Requirements Discovery (CRD). Epic is testing the API with 16 additional payers to support wider industry adoption, the company announced Monday as its annual Users Group Meeting kicks off in Verona, Wisconsin.
For providers, the technology allows clinicians to see instantly within Epic whether a medical service requires prior authorization, eliminating the need for phone calls, faxes or retyping information into separate insurance portals, according to Epic in a blog post. With this information available in real time, treatments that do not need prior authorization can begin immediately, and for those that do, the approval process can start sooner.
The real-time prior authorization API satisfies a critical Centers for Medicare and Medicaid Services (CMS) interoperability mandate set to take effect January 1, 2027. UnitedHealthcare, Network Health and Aetna are among the first group of health plans to go live with the API, while Ochsner Health, Froedtert ThedaCare Health, Denver Health and Summit Health are the four health systems now using the real-time prior auth checks.
The participating health systems say the tool will reduce administrative burden, speed care delivery and help avoid treatment delays by allowing providers to either proceed immediately when authorization is not required or begin the approval process sooner when it is.
With a goal of modernizing the prior authorization process, CMS requires certain payers to implement standardized, FHIR-based (Fast Healthcare Interoperability Resources) APIs for electronic prior authorization by January 1. The requirement effects Medicare Advantage, Medicaid, the Children's Health Insurance Program, Medicaid managed care and qualified health plans.
Working with Epic, early adopter health plans are five months ahead of the deadline, already supporting real-time insurance reviews.
“At Ochsner Health, we’re excited to implement the Prior Authorization API, which transforms a traditionally manual, time-consuming process into a streamlined experience for our care teams. This will reduce administrative burden, improve efficiency, and minimize delays in patient care,” said Melissa Woods, Ochsner Health’s assistant vice president of revenue cycle and financial clearance, in a statement.
“At Froedtert ThedaCare, we strive to be the trusted health partner with the communities we serve. That means making access to care easier, faster and more affordable,” said Imran Andrabi, M.D., president and CEO of Froedtert ThedaCare, in a statement. “Partnering with Epic, Network Health and others to launch real-time prior authorization helps our patients and teams focus on the care that’s needed.”
Electronic prior authorization workflows across the healthcare system are built upon the standards developed by the HL7 Da Vinci Project. By utilizing HL7 FHIR standards, Da Vinci created a trio of implementation guides: Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR) and Prior Authorization Support (PAS). Together, these implementation guides automate the workflow from checking rules to final submission.
The four health systems and three payers are now live with the Coverage Requirements Discovery (CRD) industry-standard API. Epic's goal is to work with payers and providers to automate the entire prior auth workflow.
"We're moving into the modern age of prior authorizations and getting away from this really disjointed process with fax machines and portals," Ryan Bohochik, vice president of value-based care at Epic, said in an interview.
Prior authorization is a significant pain point and administrative hurdle for healthcare providers. But turning on electronic prior authorization for real-time checks is not like flipping a switch. The industry standards APIs were developed over several years, according to Bohochik, who is a member of the Da Vinci Project. The focus then shifted to operationalizing the standards across provider and payer organizations to make it work in practice, Bohochik noted.
"You can have a regulatory requirement for payers, providers and technology vendors to have an API available, but just because you have it available, if no one's using it or no one knows how to connect to it, it doesn't actually provide any value," Bohochik noted. "What we've been focused on is not just that the API is available and someone could connect to it, but it's working together with the payers and providers to say 'How do we actually connect up and how do we make this useful?'"
He added, "We've had to do a heck of a lot of work with the healthcare providers to change the way that they go about doing their work. There's the old criticism that the healthcare industry is keeping the fax machine alive, so we had to go back and redesign their processes to get away from the kind of old-school way of doing things to use these real-time connections that are available."
While certain payers are required to support electronic prior authorization through standardized APIs by January 1, CMS, in a recently proposed rule, adjusted the timeline for hospitals, moving the electronic prior auth measure from an optional bonus to a mandatory requirement beginning in calendar year 2028.
While that delayed timeline creates some uncertainty in the market, Bohochik noted that Epic moving forward with integrating the API sends a signal to the industry that the work to shift to electronic prior auth is accelerating.
"By getting this out now, people will see that it's possible, that it can be done, that it's not a hypothetical. Any group that uses Epic as their EHR, it's available to them. It's essentially part of their system, and as long as the health plans that they contract with are also supporting it, then it can work," he said. "The goal for us is that we want everyone to be doing this across the board because it's a time saver and it's a better experience for physicians."
Epic also sees opportunities to leverage artificial intelligence to automate prior authorization workflows and target inefficiencies in the process.
"We're looking at what are all the tools we have available to alleviate the burden in this prior auth process. So we have the API connections now, and we have AI that we can run in the provider system to essentially interpret the information we get back from the payer and scour the record to see if all those requirements have been met," Bohochik said. "There's a ton of potential to not only have this real-time connectivity to health plans, but then automate work on top of that with the information that we get back, so that will just be part of the Epic platform."