Prior authorization will become less of a hassle for physicians in Blue Cross Blue Shield of Michigan’s network, BCBSM officials hope, as they roll out an effort to relax about 20% of prior authorization requirements.
“This is part of Blue Cross’ ongoing effort to improve healthcare quality, experience, access and affordability for members, while also reducing administrative tasks for clinicians,” BCBSM said in a press release.
Prior authorization has often been a sticking point between health plans and physicians, as UnitedHealthcare found out earlier this year when it attempted to change the process of approval for colonoscopies. Physicians and others raised such a commotion over the proposal that eventually UnitedHealthcare had to shelve the idea.
Many insurers want to use technology to help make the process less burdensome. That’s the route being taken by the Health Care Service Corporation when it announced in July that it would be utilizing augmented intelligence and artificial intelligence to process prior authorization requests 1,400 times faster than it had in the past.
Part of BCBSM’s program will be expanding its “gold carding” of physicians who have a history of making decisions based on generally accepted best practices. Those providers will be exempt from having to undergo the third-party prior authorization approval process.
Michigan in April 2022 passed a law that mandates that wait times for authorization be greatly reduced and that health plans and physicians streamline the entire process. That legislation was spearheaded by the Michigan State Medical Society (MSMS), which mentioned BCBSM’s gold carding program when it announced that Gov. Gretchen Whitmer signed the legislation into law. In a bulleted list of how the law will reform prior authorization, MSMS wrote that the law “requires an insurer to adopt a program that promotes the modification of prior authorization requirements of certain prescription drugs, medical care, or related benefits, based on the performance of the healthcare providers with respect to adherence to nationally recognized evidence-based medical guidelines and other quality criteria (i.e., BCBSM ‘gold carding’ program).”
James D. Grant, M.D., BCBSM’s senior vice president and chief medical officer, said in the press release announcing the effort to relax prior authorization requirements that “as a physician, I know firsthand what physicians and their teams experience every day. We seek to minimize the amount of time physicians, nurses and their staff spend on paperwork, the computer, and the phone. After thorough analysis, we’ve eliminated hundreds of medical procedures that previously required prior authorization review, and we can give that time back to clinical partners to care for our members.”
BCBSM said that it too will utilize technology to greatly speed up the prior authorization process.
Jeniene Edwards, BCBSM’s vice president of utilization management, said in the press release that the health plan “processes roughly 87 million claims each year, and about 2.5 million, or roughly two percent, go through the review system. Most prior authorization requests are submitted electronically and approved within seconds using automation that expedites the process. Our goal is to leverage multiple channels of technology for transparency and automation which also enables us to accelerate decisions to minimize disruption to our members.”
Grant said that “as technology platforms continue to evolve, our long-term aim is to let these advances enable us to move from a world of ‘authorization’ to ‘clinical decision support.’ This way, all stakeholders, especially physicians, nurses, their staff and our members, will be able to quickly receive transparent, evidence-based decisions and status updates through their electronic medical record. This also ensures that coordinated care moves forward safely and without delay.”