In 2018, six national advocacy associations representing physicians, health plans, pharmacists, hospitals and medical groups released a Consensus Statement Outline proposals to reform prior authorization (PA). Yet four years later, PA remains a barrier to providing timely, necessary patient care.
In 2021, 93% of physicians American Medical Association (AMA) Survey PA has been reported to cause care delays at least some of the time, and 34% of physicians said PA contributed to serious adverse events for patients in their care. While many health plans have focused on improving PA efficiency through the digitization of submissions and clinical review, this has only accelerated a broken process. It doesn’t turn the PA into a more valuable care management tool.
Contrary to popular belief, the PA process provides a valuable opportunity to encourage high-value care options. With greater interoperability, providers and health plans can share patient-specific clinical data to see the full context of a patient’s care path—including services provided by other providers—and ensure optimization from start to finish.
Make evidence-based choices for the entire stage of care
Currently, health plans treat each PA request as a single transaction with a binary outcome: “approve” or “deny.” However, with a more complete view of their members’ clinical records, health plans can proactively manage each patient’s unique care journey.
Smart empowerment platforms rely on artificial intelligence and machine learning to extract patient-specific data from multiple sources, including EHRs. With each member’s longitudinal care history, health plans can better predict, manage, and optimize member outcomes.
By automatically suggesting other services that may be suitable for bundled authorization, the intelligent platform can reduce the time and cost of PAs while facilitating high-value care decisions. Instead of submitting multiple disconnected pre-authorization requests for a single patient, physicians can pre-approve multiple services throughout the event, speeding patients to the most appropriate care.
Using evidence-based criteria, intelligent platforms can also guide physicians to the highest-value decisions. Physicians may be prompted to change an inpatient surgery request to a more appropriate outpatient setting, or to jump straight to the gold standard imaging mode, rather than requiring multiple low-value tests. This not only ensures appropriate utilization of the wider population, but also facilitates conservative treatment and reduces unnecessary testing.
Provide transparency that promotes physician trust
On the PA side, the systemic disconnect between health plans and providers is partly due to the inherent opacity of the clinical policies that drive decision-making. A health plan’s Utilization Management (UM) program is designed to evaluate the efficiency, appropriateness, and medical necessity of the treatments and services that its members receive. Of course, standards of care may vary by specialty, geography, or other factors not considered in clinical policy design.
The lack of workflow transparency in clinical policies leaves providers much to be desired.Currently, providers do not always know which services even require a PA, and almost one third (29%) felt that the PA criteria were “rarely or never evidence-based.” While health plans do use evidence-based standards to guide their policies, clinicians often do not understand how these policies are determined or what they require.
As a result, clinicians do not always know whether their PA requests meet the health plan’s standards or whether they include the correct request documentation. Health plans also operate in the dark without knowledge of a member’s nursing history and expected plan of care. This lack of transparency leads to delays and rejections that are easily avoided, which in turn erode provider-payer trust.
In order for UM to be a more collaborative process, full transparency is essential. Overview of the 2018 Consensus Statement on Improving the Prior Authorization Process Five focus areas for PA reform: Selective Application of PA; Continuity of Care; Program Review; Automation;
Creating a more transparent PA process can reduce friction because physicians are well aware that plan approval requirements are based on best practice. When physicians understand the clinical rationale behind plan policies and know in advance what is required for approval, they are more likely to accept specific high-value care recommendations.By giving providers the choice of accepting or rejecting clinical advice, and showing them why It started with a suggestion that intelligent empowerment platforms could begin to drive improvements in patient outcomes.
Accelerate the revenue cycle without increasing costs
When care is delayed or denied, provider reimbursement is also delayed, and in some cases never materialized. While the current PA process is already upstream in the revenue cycle, it does not use clinical data to influence the care a patient receives, meaning it does not necessarily promote better overall health outcomes.
Our current PA process also has little impact on membership costs. While some health plans will call members to let them know that they can undergo an approved procedure more cheaply at a different in-network facility, this intervention would be more helpful if it happened automatically during the PA process. Smart authorization models can deploy health plan-specific rules to prompt physicians to select preferred adjunctive providers, impacting the overall cost of patient procedures and encouraging cost efficiencies among providers.
The PA process is highly fragmented, which also results in delays and lost revenue. Providers typically deal with 5 to 10 health plans, each of which may have its own portal, fax process, and 278 EDI process, not to mention the wide variation in coverage policies. While some technology solutions attempt to integrate these processes with front-ends that can be used in multiple health programs, these solutions do not support meaningful clinical intelligence. PAs often require more intensive clinical information, which EDI alone cannot provide.
By enabling a single user experience for all authorization requests, an intelligent authorization platform saves providers time and accelerates revenue cycles. Such platforms facilitate clinically intelligent care paths that predict the likely course of the patient journey, recommend evidence-based courses of action, and align patients and health plans with each provider associated with an event of care. The result is better outcomes at lower cost of care, even before administrative efficiency is factored into the equation.
For providers who consistently follow these evidence-based care paths, the payment process can be significantly accelerated. By automatically expediting the PA requests of the highest performing physicians, physicians whose requests exceed accepted clinical standards can be encouraged to change their behavior. Rewarding high-performing physicians helps health plans incentivize high-value care choices, reduce variability, and satisfy providers.
If the healthcare system is to address these deep-rooted challenges, we must ensure that PAs are fully functional for both providers and health plans and are centered on improving care. When we stop seeing PA as a payer-imposed barrier and start seeing it as an opportunity for true care management, we can begin to optimize care for each patient.
Photo: Piotrekswat, Getty Images
