InterSystems begins with four sets of three related considerations when working with IT leaders at health plans to maximize ROI on new prior authorization (PA) APIs required by CMS-0057-F. The first two sets are tied directly to the regulation: the three questions these APIs must answer and three corresponding Da Vinci Implementation Guides recommended by CMS. Plans, however, must also automate the inflow and outflow of information into the FHIR data repositories underlying these PA APIs to maximize their return. This leads to the third and fourth sets of strategic considerations.
Key Considerations for Successful ePA
More specifically, providing a simple “yes” or “no” response to whether PA is required typically involves integration of information from at least three systems: member eligibility; scope of coverage; and provider contract status. And while eligibility systems are usually real-time, access to information needed to determine whether a service is covered under the governing plan contract or whether the treating provider has a special contractual relationship may be more attenuated. Plans must often account for information stored in tables and spreadsheets that are not machine-readable, in addition to myriad formats.
Likewise, medical directors at the plans we serve have outlined three separate workflows for adjudicating PA submissions: the application of proprietary guidelines by in-house staff; utilization of clinical rules engines maintained by national companies; and delegation of submissions requiring specialized knowledge like behavioral health to niche vendors. Each PA submission must be directed to one of these three paths based on the principal procedure or service code.
What comprises the optimal approach for addressing these second two sets of workflow considerations depends on each plan’s unique circumstances. Nonetheless, at least three recommendations have proven universally applicable to the plans with which we work:
1. IT leaders should forge closer working relationships with their utilization management peers. They need to map out current PA workflows and identify impacted systems together.
2. Potential gains from better automation of different PA processes should be balanced against support for such changes among impacted staff when sequencing investment or making trade-offs. Even relatively small advances in streamlining PA can deliver outsized returns, and the best driver of broader buy-in is success.
3. Deployment of an automated broker for directing PAs submitted via FHIR APIs to the right system or vendor for adjudication should still be prioritized. Otherwise, this upfront determination may prove a universal pinch-point in complying with the response timeframes in Rule 0057.
For further detail on these considerations plus other strategic questions plans should address now, listen to the InterSystems webinar on Maximize Your ROI on CMS Payer Mandates: 10 Key Questions.
Originally Published by Fierce Healthcare: https://www.fiercehealthcare.com/sponsored/think-threes-maximize-health-plan-roi-electronic-prior-authorization
