HL7, CAQH CORE team up to improve prior authorization, administrative interoperability

Doctor computer keyboard
Health Level Seven International and the Council for Affordable Quality Healthcare CORE are collaborating to move the industry toward end-to-end automation of the prior authorization process. (Getty/jacoblund)

The current prior authorization process is a major pain point for clinicians, as it's often labor-intensive and time-consuming. Health Level Seven International (HL7) and the Council for Affordable Quality Healthcare (CAQH) CORE are collaborating to move the industry toward end-to-end automation of the prior authorization process.

It's part of an effort by the two organizations to work together to improve interoperability between healthcare administrative and clinical systems.

HL7 is a nonprofit standards development organization dedicated to developing standards for the exchange of electronic healthcare data. CAQH CORE was formed by the healthcare industry to promote the adoption of healthcare operating rules that support standards and accelerate interoperability.

Accelerating the electronic exchange and interoperability of data is key to fix new and long-standing challenges in the industry, according to the organizations. It marks the first time these two organizations, which conduct complementary work to improve the electronic exchange of healthcare data, have teamed up on solutions to specific technical and administrative burdens.

RELATED: Council of Affordable Quality Healthcare CORE updates rules for prior authorization 

“Our collaboration will help move the healthcare industry towards greater automation and streamlined business processes,” April Todd, senior vice president at CAQH, said in a statement.

The two organizations will initially collaborate in three areasprior authorization, medical documentation and value-based payments.

Currently, the prior authorization process is a costly administrative burden for providers and payers. It also frustrates patients, and, in some cases, delays care, according to the organizations. Todd told FierceHealthcare the two groups will collaborate in many ways to improve this process.

"One example is pilot testing operating rules to support existing and emerging standards across the prior authorization workflow, including clinical document architecture and fast healthcare interoperability resources, to drive adoption of automated processes," she said.

According to the CAQH Index, 84% of attachments or documents that prove medical necessity are exchanged manually and often contain too much, too little or the wrong type of information. This delays prior authorizations, hinders the transition to value-based payments and costs plans and providers time and money. HL7 and CAQH CORE will work to align their respective efforts to support the electronic exchange of clinical information and medical documentation.

RELATED: 28% of physicians say prior authorization led to adverse events

The move to value-based payment models has been slowed by a patchwork of administrative and technical approaches and workarounds, the organizations said. CAQH CORE will work with HL7 to address the interoperability challenges causing an administrative burden for innovative payment models.

John Kelly, principal business advisor at healthcare technology company Edifecs, said the partnership is a "pivotal step forward" to improve interoperability as the industry adjusts to new encounter data management rulings from the Centers for Medicare & Medicaid Services and complies with new federal regulations around patient privacy.

Efforts to improve administrative and clinical interoperability will result in reduced risks for errors and revenue loss, he said.

“This will help our industry to better streamline, analyze and scale large volumes of data across the healthcare ecosystem. It’s time that health plans start thinking about how they will leverage the new payer, provider and patient data exchange requirements to support efforts that drive new care payment models—this collaboration will make this a reality," he said.

It marks a critical shift in creating a harmonized approach to dealing with the various existing and emerging standards supporting the exchange of patient information between and among stakeholders. "Especially in emphasizing the patient role as a primary agent of interoperability," he said.