HLTH24: Blue Shield of California, Salesforce join forces to streamline prior authorization

LAS VEGAS—Blue Shield of California and Salesforce are teaming up to simplify and streamline the prior authorization experience.

The partners announced at HLTH on Monday that they would leverage Salesforce's Health Cloud to make the process feel as simple as paying with a credit card. When a clinician needs to submit a prior auth request, the platform will search the patient's medical record for relevant clinical data and then pull that into a pre-populated form, the companies said.

The physician can then submit that form immediately rather than needing to wait to send a fax or make a lengthy phone call. Blue Shield said members will receive an answer during their visit, and each request will still be vetted by one of the insurer's medical directors or a licensed clinician.

Prior authorization is a well-known pain point for physicians, who are already strapped for time and resources, and patients, who may be forced to wait for critical services. A recent survey from the American Medical Association found that 78% of physicians said prior authorization can lead to patients skipping care.

"It's just really inefficient. It's painful, it's stressful for patients," Blue Shield CEO Paul Markovich told Fierce Healthcare in an interview. "And we've heard physicians, a lot of them, talk about how some of their patients end up not accessing the care they're recommending because the process takes so long and is so difficult."

While most requests can be managed quickly through this solution, there will be some that do require a clinical consult. Should this be the case, physicians will be notified in real time with details on what needs to be done to secure approval and will be provided options for a peer-to-peer consultation.

While this can take several days, Blue Shield said members will be kept up to date on the status of their request via their app, increasing transparency into the process.

The process for prior authorization submissions remains archaic; Blue Shield noted in the press release that two-thirds of requests are still submitted via fax. Jeff Amann, executive vice president and general manager for Salesforce Industries, told Fierce that he was genuinely shocked by how behind the times the process still is.

"The problem that we're solving here has been solved in other industries," he said. "To be sure to bring that technology to bear in a complex industry ... is not an easy feat, but it's also not like putting a person on Jupiter. It's totally doable."

Blue Shield and Salesforce have an established history together and have also collaborated to develop a cloud-based care management tool. Amann compared the relationship to commercials for Reese's candy: The companies go together like chocolate and peanut butter.

He said over time the collaboration has led the two to operate as "one team."

"So our job, we see it as we need to reinvent and rethink a system that's just dysfunctional and broken in so many places, but we need partners to really make that vision a reality, and in particular, modern, capable tech platforms, and Salesforce has got that in spades," Markovich said. 

"So that's really we try to bring that vision to the world ... and then try to leverage and use all of their expertise in the technical field to bring it to life," he said.