Prior authorization — the process by which health insurers determine whether they cover clinical services before someone receives them — has long been a burden for patients, providers, and payers.
Could data technology help transform prior authorization? Three industry experts say the answer is clear: Yes. Here are five takeaways from their conversation at InterSystems Virtual Summit.
1 - Manual prior authorization causes measurable harm.
Manual work and redundancies burn billions of dollars, notes Lynda Rowe, Senior Advisor, Value-based Markets, for InterSystems.
In fact, 34% of healthcare delivery organizations have dedicated staff to complete prior authorizations. Providers receive requests for roughly 14 prescriptions and 15 medical services each week, which take two workdays to process.
Manual prior authorizations contribute to care delays — 92% of which stem from inefficiencies and administrative issues.
2 - Automating prior authorization solves big challenges.
But 80% of prior authorizations requiring clinical and administrative review can be automated. That’s a win for patients, who get timely care, and payers and providers, who bear lower costs.
On average, each manual prior authorization costs $3.68. Automated prior authorizations run just $0.04.
3 - HL7 Da Vinci empowers payers and providers to streamline prior authorization.
HL7’s Da Vinci project, which produces standards and implementation guidelines to better connect payers and providers, is tackling prior authorization.
The 646-bed health system UC Davis Health, the 25.4-million-member payer Centene, and InterSystems have partnered to establish infrastructure conformant to HL7 Da Vinci implementation guides to streamline prior authorization workflows. The organizations intend to remove latency and enable real-time data sharing.
“We want to take interoperability to the next level so that we can provide a more seamless experience,” says Michael Marchant, director of health information exchange and system integration for UC Davis Health.
4 - Clinical data interoperability matters.
The project depends on connecting UC Davis Health’s EHR to Centene’s payer systems. InterSystems HealthShare acts as the intermediary, using CDS Hooks to power real-time data sharing.
The technology brokers transactions by applying rules, ensuring the right information reaches the right person when it matters most. Upon receiving a prior authorization request, Centene’s system may query UC Davis Health’s EHR to search for clinical data that supports the need for a given service, procedure, or product.
“Historically, we have tried to solve the problem with claims and attachments,” Rowe says, “when we really need clinical data and rules.
5 - Automate prior authorization now.
Automated prior authorizations are cutting edge, but that’s about to change. CMS has announced that payers must soon streamline the process. If there were ever a time to get ahead of the regulations — and make real progress for members and the business — it’s now.