Council of Affordable Quality Healthcare CORE updates rules for prior authorization

Stack of health insurance application forms with stethoscope on top
Council of Affordable Quality Healthcare CORE released the latest version of electronic prior authorization rules. (Getty/vinnstock)

Council of Affordable Quality Healthcare (CAQH) CORE recently released Phase V Operating Rules in an effort to strengthen the accuracy and consistency of the prior authorization process.

Prior authorization from an insurance company for medical procedures is consistently a pain point for patients and providers. And the process, when done manually, can cost providers and plans both time and money. That is why a group of health plans, providers and health IT companies developed CAQH CORE, a set of standards and rules to help speed up the authorization process.

The advocacy group says that the process is not only faster but more accurate when done electronically. For example, the 2018 CAQH Index reports that full adoption of the standard electronic prior authorization transaction can result in savings of more than 70% per transaction.

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So why is the process so slow in 2019?

“Prior authorizations are intended to serve as a check on potentially unnecessary, inappropriate and unsafe medical treatments. That’s why plans often require them for surgeries, diagnostic tests, procedures, medications and other categories of service,” Susan Turney, M.D., president and CEO of Marshfield Clinic Health System, told FierceHealthcare.

However, 88% of prior authorizations are conducted partially or entirely manually, either via phone or fax. This process can take hours, days or even weeks, according to the CAQH 2018 report.

CAQH CORE recently released what is known as the Phase V Operating Rules, which are meant to eliminate unnecessary back-and-forth measures, accelerate time frames and free up staff members. In the early 2000s, when HIPAA electronic transaction standards first went into place, no operating rules existed to guide implementation. So the results were the use of proprietary systems that resulted in a lot of non-uniformity among payers and providers. Ultimately, a manual process was still an efficient way of getting prior authorization.

RELATED: 28% of physicians say prior authorization led to adverse events

So when CAQH CORE was adopted, the goal was one set of operating rules and standards to align administrative and clinical activities among providers, payers and consumers.

“In particular, the rules standardize data related to the exchange of clinical information and offer providers a more consistent, efficient and predictable process across all the plans with which they participate,” Turney said.

Today, CAQH CORE has more than 130 participating organizations that include health plans representing 75% of insured Americans, providers, vendors and government entities.

“But I encourage all healthcare stakeholders to join because a variety of perspectives will help us truly solve administrative challenges,” Turney said.

According to a 2018 American Medical Association study, 65% of physicians report waiting at least one business day to receive authorization, and another 26% wait at least three business days. Plus, 91% of these same physicians cited prior authorizations resulted in delays in care.

Turney notes that the biggest challenge relates to staff members' time. On average, a manual prior authorization requires 16 minutes of provider staff time (or up to 30 minutes), versus nine minutes using electronic means (or up to 25 minutes). Plus, this is time spent just to complete a transaction and does not include any follow-up work that might be necessary.

Moving forward, automation will play a large role in improving the prior authorization process, Turney said.

RELATED: 5 ways physicians, payers will work together to streamline prior authorizations

“The solution lies in getting the industry to standardize the data that needs to be shared and automate the process so that it can happen quickly and accurately. We can’t forget that prior authorizations exist to help patients—and we need to fix processes that can delay necessary care,” Turney said.

Turney notes that payers have been a large driver in the push to improve the process. And CAQH CORE collaboration encourages more payers to adopt the operating rules and get CORE certified in order to move the industry further toward automation.

The 2018 CAQH Index estimated that 182 million prior authorizations occurred, a 14% increase compared to 2017 and a 27% increase compared to 2016.

And there is still work to be done.

According to Turney, the Phase IV rules established the foundational infrastructure requirements such as connectivity and response time. And in Phase V, the group addressed the needed data in the process and enabled greater consistency across other modes of prior authorization submissions.

Right now, the organization is pilot testing requirements for a provider to determine whether authorization is truly needed. Also, the group will evaluate and support emerging standards that have the potential to alleviate pain points in the process. Ultimately, CAQH CORE wants to remove barriers to value-based payments.

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