Breakthroughs in Prior Authorization Automation: An Expert Offers Insights

With new breakthroughs happening in electronic prior authorization technology, industry stakeholders are curious what CMS may ultimately mandate in its forthcoming final rule and what types of solutions will help facilitate the changes.

A resident expert from MCG Health answered questions about potential approaches the federal government might take as well as new technologies that could support the evolution of authorizations. Rajesh Godavarthi, the Associate Vice President of Technology and Interoperability at MCG Health, who also serves on the WEDI Board of Directors and the ONC HITAC, discusses these important topics below.

Question: With regard to the healthcare industry’s efforts to automate prior authorization decisions and pending rules from CMS, are there any new updates on that front?

Rajesh Godavarthi: As it pertains to the federal government, I feel that the establishment of electronic standards around prior authorization is among their highest priorities. It ranks up there with efforts to promote health equity and a couple of other initiatives. They know the burden of prior auth is real, and they understand how it can impact patient outcomes.

Earlier this year, the Office of the National Coordinator for Health Information Technology (ONC) put out a request for information (RFI) to gather data from a wide array of healthcare stakeholders, like the American Medical Association (AMA), the American Hospital Association (AHA), and the Council for Affordable Quality Healthcare (CAQH) – a lot of prominent organizations – to look at ways to develop a criteria for the best ways to approach EMRs (electronic medical records). And by that, I mean how can they enable the EMRs to support the necessary data elements and workflows that can be expose to the payers (or the technology partners) to automate the process. They’re currently looking at the best ways to start a certification process. However, they do acknowledge that the HL7® Da Vinci Project standards are not fully matured to impose as a strict criteria. They will probably take a more measured approach that allows the industry to mature a little bit and have some pilot studies or connectathons. I think once they start seeing more industry progress, they will start creating specific certification criteria around the question, “Does this require prior auth?” And then they’ll look at the next piece. So, instead of saying health plans and health systems need to have an end-to-end automation in place (according to the specs), I think they’ll take a more modular approach.

Q: There was a lot of buzz at HIMSS 2022 in Orlando about MCG Health’s advances in interoperability and automating authorization decisions. Your company appears to be ahead of the curve in this area. Can you tell us a little about that?

RG: Yes. MCG has been working with a large payer and two hospital systems based in Ohio. We’ve started automating their inpatient workflows which are pretty complex when compared to elective procedures and prior auth. The work that MCG has done with all sides to facilitate the communication between the payer and provider systems helps enable a clean exchange of data for authorizations. What we have learned since we rolled out our Cite for Collaborative Care solution last year, is that you need to make the statuses of the authorization transparent at every point of communication so that providers know (1) their auth request has been delivered successfully to the payer, (2) it has been reviewed by the payer, and then (3) the determination is transmitted back. We have seen a tremendous success and rapid adoption as these hospitals asked us to add more facilities and end users. Today, 70% of the authorization decisions from these hospitals to the payer are being automated through this platform.

Q: Integrating a solution like this into the hospital EHR platforms and the payer’s utilization management (UM) system sounds challenging. What were some of the top learning moments for this type of project?

RG: On the EMR side, we have worked with CarePort and Allscripts for this project. They control the actual provider workflow, so we collaborated with them to make sure the APIs (application programming interfaces) are implemented properly so that the hospital staff can know their request has been submitted and they can seamlessly receive the status. The MCG team worked very closely with CarePort to make sure everything worked, and this dovetails into everything MCG is also doing with the HL7® Da Vinci Project. We are working with other industry leaders to develop the standards such as “How do you create a CDS hook?” so that things can be initiated from the provider. Much of the work we’ve done as a part of the HL7® Da Vinci Project is to make the providers’ workflow much more seamless so that they don’t have to do any additional actions to get complete the authorization request. With the payer’s medical management system (MMS), we learned that there is a lot of information on their side, but not everything is exposed. At least to the point where we can take it and communicate it to the provider. In those cases, we initiated certain extensions to get the information about the status – whether it is approved, denied, or pended – and relay that back to the provider. We just had to work with the different systems to learn what information needed to be shared and then we built the pipes that could deliver it between the payer and provider.

Q: What has the feedback been from these hospitals systems using the platform?

RG: As of today, one of the hospital systems is sending all emergent cases to the payer via this platform which is anywhere from 45-70 cases per day. Since they are receiving authorization determinations via their EHR, this has reduced the faxes they receive from the payer by about 800 per month. This is a 57% reduction in faxes for their hospital system, and it has saved about 20 hours per week of manual, administrative burden. They also reported significant increase in employee satisfaction (especially around auto approvals), and their UM staff felt the streamlined workflow. We are currently in discussions with them to expand the use of the platform in other use cases.

Learn more about what is being done to reduce the burdens of prior authorization for both providers and payers.

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Whitepapers

Featured Webinars