Preparing for the Return of Prior Auth

The COVID-19 pandemic is changing the way we live and work in dramatic ways. Among the many changes to the delivery of care, prior authorization processes have been suspended by many payer organizations, including the CMS. Inevitably, however, prior auth will be coming back, and healthcare organizations that have adapted to adjust to pandemic conditions will have to reorient their processes once again.

The Costs of Manual Submission

Unfortunately, in many cases, existing prior auth processes are outdated or even broken. According to the most recent figures from the Council for Affordable Quality Healthcare (CAQH), 88% of provider offices still rely on faxes and phone calls to conduct prior auth. These outdated “manual” forms of communication are prone to error and misinterpretation, and it is estimated that they take seven minutes longer per claim to process than their electronic submission counterparts. This averages out to an additional cost of $3.47 for payers per claim ($3.81 for providers), or a total of $417 million for the industry overall.

Ultimately, the individual with the most to lose in the world of manual prior auth is the member. The inefficiencies and errors resulting from fax- and phone-based processes can have downstream effects that inhibit appropriate care. In a survey by the American Medical Association, 92% of clinicians said that lengthy prior auth protocols had a negative impact on member access to care and clinical outcomes.

With many prior auth requirements currently on pause, this is a golden opportunity to improve member access to care, reduce reviewer burden, and drive down health plan costs by making the move to an automated process.

Challenges to Automating Prior Auth Determinations

While electronic prior auth submission may be an effective solution to streamlining these processes, implementing it comes with its own challenges. After all, each auth request—even if submitted electronically—needs to include the clinical information detailing the medical necessity. While cut-and-paste is an option, that too is a manual process that is prone to error, or even simply being forgotten among other steps.

Additionally, interoperability between healthcare systems (or the lack thereof) remains a large obstacle. There are organizations such as HL7®’s Da Vinci Project currently tackling the problem of developing an industry standard, but up until now it has been a patchwork of different technologies. Any electronic solution deployed by a health plan today would not only have to communicate with the disparate provider systems currently in their network, but also scale with the standards of tomorrow that are still being developed.

Aligning Systems to Unlock Automation

As the leader in evidence-based care guidelines, MCG Health has become a trusted resource for clinical guidance between payers and providers in the prior auth process. To help streamline the workflow, MCG offers Cite AutoAuth, a web-based solution that connects the critical pieces of medical necessity and automation technology. AutoAuth has the ability to integrate with existing providers portals, making it easy for payer organizations to support timely, evidence-based treatment. Through the payer portal, health plans receive electronic auth requests with the medical necessity documentation included for an efficient review and response. AutoAuth also allows health plans to implement custom organization-specific rules for approvals, based on the robust evidence of MCG care guidelines, enabling them to auto-approve requests with no staff intervention (when the appropriate conditions are met) or pend requests for further review.

Health plans leveraging AutoAuth for prior auth processes have enjoyed large gains in efficiency. One major health plan in Ohio saw prior auth costs drop by 80% after implementing AutoAuth, with 79% of their cases completed in the portal being approved without any staff intervention. When the floodgates open on prior auth once more, AutoAuth will be there at the ready.

Learn more and request a demo of MCG Cite AutoAuth by reaching out to MCG.

Image courtesy Shutterstock/Dragon Images

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