In this white paper, Mark Kausel, Director Client Services, IT, discusses the inefficiencies and challenges of the current prior authorization process, highlighting its impact on costs, care delivery, and patient outcomes. He emphasizes the need for a more efficient, automated solution to handle prior authorization requests in real time and reduce delays.
Please click on the video to the right to learn more about the author, his paper’s key takeaways, and his motivation for writing on this subject.
To discuss this white paper in detail, please reach out to Mark using the contact information provided at the bottom of the page.
Everyone acknowledges that the US healthcare system has many inefficiencies that drive costs up and impede the delivery of care. The current prior authorization (PA) process is a perfect example of this as it is fraught with issues that create higher costs, frustration for care providers, and more importantly can lead to adverse outcomes when patients are not treated timely and judiciously.
Meet Maryann. She faced significant delays in receiving a crucial cancer treatment due to prior authorization requirements by her health insurance company. Maryanne, diagnosed with ovarian cancer, required a specific chemotherapy drug prescribed by her oncologist. However, a prior authorization needed to be obtained from the health plan, which took several long weeks to process. During this time, Maryanne's condition deteriorated, and the cancer spread, necessitating more aggressive treatment when the authorization finally came through.
The more aggressive treatment led to Maryanne enduring more pain, suffering, anxiety, and a much longer recovery. It meant she was away from work longer, and the cost of the treatment was higher. This scenario and scenarios like this one are easily preventable with timely authorization approval. Even better, imagine a world where the authorization is not needed in the first place.
Each year, the American Medical Association (AMA) conducts a nationwide survey of 1,000 practicing physicians to understand the impact the PA process has on patients, physicians, employers, and overall healthcare spending. The information below summarizes some of the results of the 2023 AMA prior authorization physician survey:1
The administrative burden, the added cost of care, and the adverse impact on patients continues to be a crisis. The Center for Medicare & Medicaid Services (CMS) has issued its final rule, CMS Interoperability and Prior Authorization (CMS-0057-F), to advance interoperability and improve the prior authorization process. This rule requires “impacted payers” to “implement and maintain certain Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs) to improve the electronic exchange of health care data, as well as to streamline prior authorization processes.”2
These requirements will slowly have an impact on making the prior authorization process more efficient, reducing the administrative burden on providers and enabling patients to get the care they need when and where it is most appropriate.
Let’s take a moment to understand the current process that consists of the four main steps illustrated below:
By looking at this convoluted process flow, it is evident that there is a huge need to move from the segmented, manual processes with all the “hoops that need to be jumped through” before patients like Maryanne can receive the care they need to a seamless, automated solution.
While at her appointment, Maryanne’s oncologist writes the order for the specific chemotherapy drug and treatment. Immediately, the Electronic Medical Record (EMR) sends an electronic message to Maryanne’s insurance company.
The payer responds in real time, confirming Maryanne has insurance coverage and that the chemotherapy drug and treatment require prior authorization. Then, leveraging artificial intelligence, an Intelligent Automation Platform (IAP) determines what information is required to successfully obtain the authorization approval for the treatment, packaging it up and sending it to the payer electronically.
At the payer, the authorization request is reviewed using artificial intelligence to read the request and make a determination based on the care guidelines created through evidence-based medicine. Without human intervention, the authorization is approved and communicated back to the Intelligent Automation Platform and EMR… all while Maryanne is sitting in the appointment with her oncologist!
The CMS rule that was released earlier this year sets the stage for this new world by requiring the exchange of information electronically to streamline the process and shorten the time to make determinations. While the requirements need to be met by January 1, 2027, for government payers, commercial payers typically follow in similar timeframes. In the shorter term, an Intelligent Automation Platform can be levereged to streamline the process.
By leveraging an Intelligent Automation Platform, Vee Healthtek streamlines the prior authorization process even today to effectively manage different technologies (i.e., AI, RPA, NLP, etc.) and human intervention when required to move a prior authorization through to completion seamlessly. Creating a standardized and automated prior authorization process will happen, but there are many silos of information, stakeholders (payers, providers, and patients), and differences in agendas that must be aligned for that to happen.
CMS has provided a framework and incentives to move the US healthcare system in that direction, but it will be a crawl. In the meantime, Vee Healthtek will continue to leverage Intelligent Automation to help its clients achieve this goal today, ultimately benefiting patients.
12023 AMA prior authorization physician survey
2CMS Interoperability and Prior Authorization Final Rule CMS-0057-F, January 17. 2024
