On June 7, 2021, NEHI, the New England Healthcare Exchange Network (NEHEN), and the Massachusetts Health Data Consortium (MHDC) co-hosted a Webinar titled ‘Innovations in Automation of Prior Authorization: Tackling the Issues from a Multi-Stakeholder Perspective.’ Prior authorization is a form of utilization management requiring providers to obtain permission from a health plan before delivering specific services to patients, thereby ensuring patients receive medically necessary, cost-effective, and evidence-based care. The webinar offered providers and health plan representatives an opportunity to engage with panelists from innovative companies that provide different solutions focused on the automation and improvement of prior authorization processes.
What is the problem? The U.S. healthcare system encompasses a multitude of health plans, and though plans typically adhere to similar principles in deciding when prior authorization is necessary and which criteria to use in approving requests, there are material variations in the services subject to prior authorization and in the standards for approval across payers. Prior authorization occurs primarily via telephone, fax, and postal mail, adding to the complexity of the process. It has been blamed for wasted time and money, as well as delays in patient care.
Why automation? Automation offers the possibility of a touchless prior authorization process by extracting necessary documentation from a provider’s electronic health record (EHR) based upon criteria for prior authorization associated with the service prescribed. It builds on solutions that rely on electronic submission of documentation and promises to reduce denials based on insufficient documentation, which is the most frequent reason for payers’ authorization denials. The automation of prior authorization is seen as a necessary reform to reduce provider and payer time and costs associated with the handling of requests and consequently improve the speed with which patients receive appropriate care.
How do we automate prior authorization? Noting that use of electronic portals is inconsistent, our webinar featured three companies that have focused on creating applications into account provider and payer workflows. Our three presenters were: Cohere Health, Olive/Verata, and Mettle Solutions. They discussed the following features of their products:
So, is automation around the corner? Not quite.
As we move toward automation, and we must, there are reforms we can pursue to address the challenges of prior authorization for payers and providers alike. NEHI is currently working with a Massachusetts Steering Committee comprising payers, providers, employer, and patient representatives to develop a Massachusetts-specific consensus statement that recommends process and/or application-based solutions and reforms that will complement automation and produce more immediate benefits. The Steering Committee will meet for its third and final convening later this month to finalize its recommendations. Look for NEHI’s project results this fall!