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:
- Automated clinical review. The criteria for demonstrating “medical necessity” may differ among health plans, requiring providers to sort through different requirements, with different elements of documentation. The various tools’ clinical review features and automation helps clarify the information required at the point of care, extracts much of that information from the EHR, and offers providers an opportunity to review and augment the collected health information prior to submission, thus saving time and effort. For cases when providers must respond to prior authorization information manually, the structured questionnaires and tools guide the provider through branching logic to simplify data collection. On the payer side, AI tools assist in auto-evaluation of submitted documentation for as close to ‘touchless’ and ‘real-time’ processing as possible.
- Information repositories. To improve the transparency of health plans’ medical necessity criteria and enable the provider and patient to understand what is needed to receive approval, the products: 1) automatically incorporate health plan policies once uploaded; 2) determine whether prior authorization is necessary for a specific service; 3) verify what information is needed by the payer; and 4) house documentation outlining submission and medically necessary criteria. These ‘rules engines’ comprise the Coverage Requirements Discovery (CRD) and Documentation, Templates, and Rules (DTR) portions of the Da Vinci standard. The data is exchanged securely using FHIR and REST API services between health plan and provider.
- Ease of integration. Currently, many providers submit prior authorization requests through multiple portals to the various payers that have them. Utilizing any of the three companies’ tools, providers can either integrate the tool within their current EHR or leverage one portal enabling them to communicate with all payers connected, with the caveat that payers’ systems must be interoperable and compliant with industry standard methods. The HL7 and Da Vinci workgroup for prior authorization is the most widely accepted industry standard group. The tools are currently compatible with the most common EHR software packages, although further expansion will be required.
- Scale. The tools are, or will be by the end of the year, available across the U.S.
So, is automation around the corner? Not quite.
- Uptake. Costs to build and implement automation tools remain significant barriers to adoption. At present, these tools are not fully integrated into provider workflows; they still require workflow and automation adoption within existing EHR environments.
- Interoperability. The ability for payer and provider systems to communicate is essential for automation to function. While standards for communication have been developed (e.g., Da Vinci), these are neither regulated nor adopted across private payers.
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!
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