A look at how Cigna's eviCore is rethinking automated prior authorization

While prior authorization is a key tool in an insurer's arsenal as it thinks about managing costs, the process remains a key source of friction with physicians.

Amid a nationwide conversation around addressing physician burnout and stress, plans are seeking ways to grow automated and virtual prior auth technologies to ease those barriers. At eviCore Healthcare, the benefit management arm of Cigna's Evernorth subsidiary, the team has found one of the keys to success in this endeavor is bringing physicians into the conversation early on.

Eric Gratias, M.D., eviCore's chief medical officer, told Fierce Healthcare that prior authorization programs are often built by people who, while well-intentioned, lack first-hand knowledge of what a clinical encounter is like.

The company's own prior authorization technology, intelliPath, is built on collaboration with physicians who are actively practicing, he said.

"That partnership with our provider clients is absolutely critical for our success," Gratias said.

On the other hand, companies like eviCore can be a critical partner in helping docs identify the gaps in their own knowledge, Gratias said. For example, as a pediatric oncologist, Gratias was tasked with crafting guidance for that space. Pediatric oncology lacks a national "standing order" to follow, and Gratias found through the process he identified his own blind spots that had formed as medical practice shifted.

Given the current pace of technological innovation, medical knowledge shifts quickly, he said, and what a doc learned in medical school may be very different to what's expected even a few years later. With that in mind, utilization management programs like prior authorization can help mitigate those gaps and ensure members are receiving the most appropriate care possible.

IntelliPath is embedded in the electronic health record and is streamlined through a single application that manages requests and clinical surveys, as well as provides real-time decisions. The platform initially launched in 2020 with seven providers on board and since then has grown to 38 participants.

Gratias said that eviCore is aiming to double that number the end of the year.

When a request is submitted through the system, it automatically approves those that meet clinical guidelines. If it doesn't meet those standards, it will flag the potential concern for a doc in real-time, Gratias said.

The intelliPath platform saves 10 minutes of administrative time on average per case, Gratias said. That could translate to thousands of hours saved each year for a provider.

The response from participating docs so far has been positive, as there is a significant interest in tools that can help manage the time it takes to submit prior authorization requests.

"We have been automating our eviCore prior authorization requests using intelliPath, and our practices have seen a significant increase in immediate approvals and accelerated turnaround times," said Maureen Crocco, AdvantageCare Physicians AVP, Patient Access, in a statement. "We look forward to continuing our work with eviCore and implementing innovations which allow us to focus on patient care."

And as eviCore eyes expansion for intelliPath, it's also looking to expand the platform's capabilities, Gratias said. The company is now piloting a more advanced version of the platform with two of its provider clients, which it hopes will be able to vet more complex requests.

He said eviCore hopes to have the results of that pilot by the end of this year.

"It’s been a long journey," Gratias said. "It’s coming just in time. The pressure is at an all time high, so the need for something like this has never been greater."