How Regence took a tech-enabled approach to overhauling prior authorization

Prior authorization is a commonly-cited pain point for physicians, leading to potentially lengthy delays in care as docs await insurers' OK to proceed with treatment.

That's why Portland-based health plan Regence undertook a 15-month pilot with Availity, a real-time health information network that connects to more than 2,700 payers nationwide, and MCG Health, part of the Hearst Health Network, to find tech-enabled ways to ease the administrative burden on physicians.

The health plan, which is part of Cambia Health Solutions, rolled out both electronic authorization and pre-authorization options that aimed to speed up the process.

Cheryl Pegus, M.D., president of consumer health solutions at Regence, told Fierce Healthcare that the insurer conducted surveys of both providers and patients to gauge where to begin in addressing this issue.

"I think what’s interesting for us from that research and experience is that small practices and large practices have the same issues," she said.

RELATED: Industry Voices—Taking the pain out of prior authorization management through automation

Pegus said that one of the first challenges in the pilot was making physicians aware that these tools were at their disposal.

Once they were used more widely, one of the biggest findings over the course of the study was that large swaths of prior auth requests submitted electronically were not necessary, with 58% of requests on average submitted for services that did not require prior authorization.

Physicians were notified within seconds of submissions that were not required, cutting down significant lag time on a response. 

In addition, electronic pre-authorization for more than 200 medical policies shortens the approval time to 20 seconds when conditions are met, allowing for care to proceed immediately. Submitting electronic approvals could take 20 minutes or more otherwise.

RELATED: AMA pushes for federal intervention to reform prior authorization

Using these platforms in tandem saved 6,190 days, or 17 years, of member's and provider's time. Over the course of the pilot, auto approvals were up to six days faster than those initiated by docs via phone, fax or email.

At the end of 2019, about 60% of prior authorization requests were submitted via the electronic authorization and auto authorization platforms, a number that has risen to 75% this year, Pegus said. The insurers' most engaged users submit 95% of prior authorization requests through these platforms.

In addition, these tools offer data that can be used for continuing provider education, Regence found. The insurer can generate "missed opportunity" reports that physicians can use to see where they can use the tools more effectively, for example.

Pegus said it's also been crucial to "help [practices] understand that our goal here is to make this a lot easier for them."

"Being able to do that really allowed us to build great relationships and partnerships with our practices," she said.

While many physicians have been sharp critics of prior authorization, arguing it is a key contributor to burnout, insurers have defended the practice as a critical tool to manage healthcare costs and avoid unnecessary care.