The quality of the payer-provider relationship can be one of the most critical elements to impact a member’s healthcare experience. Recently, the industry has seen an increase in direct collaboration between payers and provider networks as both sides shift to value-based care models and seek ways to reduce costs. A 2017 survey of 40 health plans and 400 practice and facility-based providers conducted by Availity found that approximately 76% of respondents across both groups identified administrative waste as a significant challenge to their business relationship.1 Long wait times on the phone and inconsistent application of medical policies ranked high as points of frustration. Fortunately, solutions exist to help reduce this type of abrasion.
MCG Health’s Cite AutoAuth, a module within the Cite software suite, combines evidence-based clinical content with automation technology to give prior auth information in real-time and reduce administrative burden for both payers and providers.
Automating Medical Necessity Review
By leveraging the Met/Not Met criteria present in the MCG care guidelines, medical necessity review can be automated for the following MCG content volumes:
- Ambulatory Care
- Inpatient & Surgical Care
- General Recovery Care (some limitations apply to this volume)
- Behavioral Health Care
- Recovery Facility Care
- Home Care
- Medicare Compliance (MCG-formatted Medicare NCDs and LCDs)
Customizable Rules Engine
Payers or TPAs (third party administrators) can leverage the customizable rules engine within Cite AutoAuth (or within an integration partner system) to:
- Automatically approve or pend service codes based on medical or business policies
- Display messages to your providers to communicate areas where additional clinical information may be needed
- Capture additional data as needed with user-defined fields
- Assign a level of care to the request, or assign a length of stay
Benefits of Automating Authorization Decisions
- Provider Satisfaction: MCG has received feedback from many health plans and TPAs, that provider networks using the Cite AutoAuth portal have reported very high satisfaction, including one Indiana-based client reporting 90% satisfaction among its providers. With 24-7 access, providers can be aware (in real time) of prior auth approvals, pended requests, or denials. Even when authorizations are not approved, this gives providers the knowledge that they may need to pursue alternatives of care. The improved turnaround times can also help payers meet NCQA standards to maintain or achieve accreditation.
- Ensure Appropriate Care: By focusing on evidence-based guidelines, payers can educate providers on best practices for certain procedures or diagnosis codes. MCG care guidelines incorporate references to vetted, clinical evidence which can be critical in payer-provider conversations. A regional health plan reported reducing unnecessary imaging tests by 39% through the utilization of Cite AutoAuth.
- Control Costs: By automating auth requests, health plan staff can avoid the manual data entry from faxes (also reducing the likelihood of errors) and focus more time on pended requests which can require more in-depth, clinical knowledge to process. This positively impacts turnaround time on prior auth requests, increases productivity, and improves employee job satisfaction. A major health plan in Ohio reported saving $3.3 million in costs after incorporating Cite AutoAuth into their process redesign.
Best Practices to Increase Provider Adoption of Prior Authorization Solutions
Getting providers to adopt such solutions can also pose obstacles for payers and TPAs, but proven techniques and strategies can help bring provider networks on board:
Define and Use Pilot Groups: Selecting a specific provider group to launch a prior auth automation solution has shown to be more effective than a mass rollout. By keeping the launch limited at the outset, lessons can be learned, and the process optimized for the greater whole. The approach shows thoughtful consideration of the provider’s time and resources.
Early Provider Engagement: Notify providers that the prior auth automation is coming well before the go-live and build in communication touchpoints on the project’s path to launch. This should include developing an FAQ site or document that they can reference for additional information and tailoring it to your provider network to address concerns specific to your relationship.
Incentivize Adoption: If possible, develop incentives for the providers to utilize the portal. One means of doing this would be to find a high-volume type of auth request with a 95% approval rate (and which is currently done manually) and create rules to approve them in real-time when medical necessity criteria is met. This will help show providers there is time savings attached to portal usage and expedite adoption.
Respond within the Solution: Communicating answers to provider questions via the solution rather than faxing back, can help acclimate providers to using the system and drives engagement on the platform rather than via outside means.
If you are interested in learning more about MCG and the capabilities of Cite AutoAuth, click here.
- Availity Releases Survey on Payer-Provider Collaboration Gaps. June 28, 2017. Source: https://www.availity.com/about-us/news-center/payer-provider-collaboration-gaps