Prior Authorization: A Standard Practice that Needs Industry Standards
In a future state, the automation of prior authorization decisions would be a natural element of high quality, value-based care. After all, the goal of prior authorization is to ensure that a member’s treatment is appropriate, cost effective, and medically necessary. However, the process of prior authorization is currently weighed down by a mix-and-match of legacy software systems that have challenges speaking to one another. In addition, providers can often not see the payer’s requirements for approval. These obstacles lead to confusion, excessive faxing, administrative waste, and worst of all, delays in member care. In order to fulfill the promise of seamless and timely prior authorization, the process must adopt new interoperability standards.
Payer Perspective
From a payer’s perspective, the benefits of leveraging standards are significant: administrative work could be drastically reduced while members receive more timely decisions about approval status, which can have a positive impact on member satisfaction. Leveraging the same technology in related use cases (ambulatory procedures, Medicare compliance, etc.) and in combination with evidence-based clinical decision support software can unlock even more efficiencies and opportunities for payers down the road.
In addition, CMS has hinted that new rules mandating interoperability standards in prior auth are coming. A previous proposed rule (which was rescinded for further review) required Medicaid and associated plans (CHIP, QHP, etc.) to implement the HL7® Fast Healthcare Interoperability Resources (FHIR®) standard. The rule is still being considered and is expected to pass in some form. In other words, these standards are fast-approaching; in order to remain competitive for Medicaid contracts (and others down the line), the time to start implementing these standards is now.
Provider Perspective
Generally speaking, what a provider wants out of prior authorization is the equitable availability of the appropriate tests and treatments for the member. They seek timeliness, simplicity, efficiency, and transparency on items such as costs and requirements. Their challenges include working with multiple payers, being forced to rely on fax for systems that are antiquated and trying to avoid delays in auth determinations. For them, there are several administrative layers and barriers inherent to the process that they want to see removed. To remove those barriers, a common standard for communication would need to be implemented across systems. Payers would then be able to seamlessly interface with the provider’s electronic health record (EHR) of choice to present their requirements and deliver real-time determinations, freeing up providers to focus more on care delivery and driving positive health outcomes for members.
ACO Perspective
As custodians of value-based care, accountable care organizations (ACOs) work with a plethora of provider EHRs and payer utilization management platforms. Their appetite for a common standard is even greater because they must bridge so many systems while trying to deliver more value for members. They have long queues of authorizations that rely on phone calls to get cleared up and then communicate back to the provider at the point of care.
For ACOs, bridging the gap between these systems would free up tremendous resources that could be better put to use in delivering member care. One ACO working with MCG Health to automate authorizations for certain emergent inpatient admissions (a different but related workflow) was able to bring their phone queue down to 5% of what it had been previously. To apply time savings such as that to prior authorization would be transformational and allow ACOs to more efficiently devote valuable resources to member care.
Standards-Based Solutions
Shifting to the HL7® FHIR® standard would allow payers to communicate with provider systems and EHRs in a one-size-fits all manner, however, overhauling legacy systems to implement the new standard can be a daunting prospect. Fortunately, industry groups such as the HL7® Da Vinci Project have been working with stakeholders across the healthcare community to create Implementation Guides (IGs) on how to use HL7® FHIR® effectively.
In addition, technology providers such as MCG have been building out solutions that leverage HL7® FHIR® to successfully enable two-way communication with provider EHRs. MCG’s leadership has been involved with the HL7® Da Vinci Project (among others) to help advance standards while also preparing their solutions for both payers and providers to fully embrace the potential of HL7® FHIR®. MCG Cite for Collaborative Care leverages the industry’s gold-standard, evidence-based clinical guidelines in machine-readable format to help guide providers at the point of care.
When the payer receives the request via Collaborative Care (directly from the provider’s EHR), relevant clinical data is already matched to the guideline, making it simple to approve, pend, or deny according to the evidence (and potentially their medical policy). The same engine allows payers to set up rules for automating approvals in certain cases. This in itself is an incredible value; as a large payer client of MCG recently pointed out, about 60% of their prior auth requests are for codes that don’t actually require prior auth. As such, those requests can be automated, saving a tremendous amount of time and resources.
To learn more about MCG Cite for Collaborative Care and leveraging these new interoperability standards, contact MCG Health here.