Elevance Health is making strides toward a simpler and more streamlined clinical review process through its Health OS platform.
Health OS is a secure data platform the insurer built to unify data from key sources, such as electronic health records, labs and health information exchanges, to support faster clinical decisions without the need for greater administrative effort from providers.
It also connects with other data systems, such as Epic's Payer Platform, to collate necessary data. Elevance was the first to lean on Epic's tool to address inpatient concurrent care reviews, which occur when a patient is admitted for one condition, such as treatment for pneumonia, and then develop a concurrent issue, such as sepsis.
These types of reviews have traditionally required manual documentation, which can lead to delays, incomplete information or additional administrative effort.
Ashok Chennuru, chief data and digital transformation officer at Elevance Health, told Fierce Healthcare that Epic's platform helps to bring various data sources into a common format, making it easier for the team to use. Epic's integration with many providers also enables prior authorization in a more streamlined way, he said.
This effort around concurrent reviews fits within a broader push at Elevance on payment accuracy and integrity, ensuring that claims are appropriately paid from the get-go, he said.
Chennuru said that denials are often due to missing or lacking information. Addressing that is a positive for everyone involved in the transaction: the payer, the provider and the patient.
"Most of the providers we have talked to are willing to work with us," he said, "because they're seeing a clear win-win for both of us."
Through Health OS, the insurer has seen a 61% decrease in prior authorization denials and 60% fewer cases set to "pending" due to missing information related to concurrent reviews.
In addition, Elevance has found a 51% decrease in follow-up reviews, including peer-to-peer discussions and appeals, as information submitted is more complete. It has also saved about 15 minutes in administrative time per case with some health system partners.
Chennuru pointed to the time savings as a significant positive shift resulting from the program. The platform also supports greater transparency for providers, the insurer said.
"Now, we can have them focus on real value," Chennuru said.
Beyond concurrent reviews, Elevance Health is also leaning on Health OS as it enhances its use of electronic prior authorization. The insurer is one of many firms that signed on to an industry pledge last year to shift toward electronic prior auth submissions.
In the announcement, Elevance said that it has processed more than 250,000 prior authorizations electronically since April, with 30 health systems actively participating in its digital program.
Of these decisions, 42% were resolved in one minute or less, the insurer said.
Electronic prior authorization leads to faster decisions for patients and further reduces the administrative work required to manage submissions, the company said.
Chennuru said that these programs are a key step on the path toward a more technologically enabled future, where these administrative processes run far more smoothly to the benefit of all stakeholders.
"We are not only leveraging that information to push gaps in care and other clinical insights and next best action to help the provider, but we are also using it to simplify the administrative processes," he said. "That's really where we see this going."