What CMS’ push for electronic prior authorization means for healthcare providers and payers

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Prior authorization is a complex, expensive and burdensome process with clinical and financial impacts across the spectrum of care. Built on processes that are mostly manual, even partial automation of submissions and other routine tasks could ease some of the burden to providers- but adoption of existing automation tools has been slow. Seventy-nine percent of authorization transactions last year were still totally manual.

In January 2021, the Center for Medicare and Medicaid Services published a new rule to push payer organizations towards adoption of electronic prior authorization. The rule requires payers to use FHIR-based APIs to show authorization requirements to providers within the EHR at the point of order; to gather appropriate clinical data to support the authorization request directly from the EHR; to receive and send submissions and status updates electronically; and to report metrics on approvals, denials, appeals and response times. The Biden administration paused this legislation after taking office Jan. 20, and the future of the rule is currently uncertain.

Andrew Johnson, vice president for prior authorization solutions at Change Healthcare, discussed what the CMS rule on interoperability and prior authorization means for health system leaders.

"Looking at the data, it’s clear that there is a significant financial and economic gain for an accelerated process or a much less manual process for providers and their authorization staff," Mr. Johnson said.

He pointed out that the drive towards electronic prior authorization is a journey that Change Healthcare has been on for the past few years.

“We’ve been focused on developing an exception-based authorization process from end-to-end, which ultimately — in the spirit of this proposed legislation — is to increase administrative savings while decreasing administrative burden,” he said.

Change Healthcare's InterQual Connect and InterQual AutoReview are digital platforms that can automate processes to help health systems meet prior authorization standards. InterQual Connect provides authorization connectivity and is designed to streamline collaboration between payers and providers. InterQual AutoReview populates reviews with needed data from the EHR, lowering the time spent on the medical review process.

"What we've specifically seen with InterQual AutoReview and InterQual Connect is the ability to reliably and meaningfully at those points of an order, admission or authorization, identify if an authorization is required and reliably extract the relevant information for a medical necessity review and via InterQual Connect's automated authorization connectivity, deliver that in real time to payers' utilization management workflows,” Mr. Johnson said.

“This is an example that electronic prior authorization can become a reality,” he notes. “Making it happen comes down to all parties — vendors, providers and payers — agreeing and adopting these standards and improving them over time. At Change Healthcare, we were on this journey before standards were adopted, so we’re very excited to have a true handshake with widely- adopted standards as they mature to deliver an end-to-end authorization experience.”
Mr. Johnson emphasized that change is a matter of when, not if. “Start planning now,” he said. “It is imperative that you understand your organization’s readiness. Do you have a strategy? Do you have core technologies in place to meet the requirement? How ready are your vendors? Do you know your UM and medical necessity vendors’ strategy? Is their content machine-readable and supportive of these APIs? How are they codifying their data so that is accessible to provider workflows?”

“A bright future is upon us,” Mr. Johnson believes. “As with all things regulatory, the rule on prior auth may be diluted, it may be delayed, but based on the amount of support for the ideals embodied in the rule, it will drive the industry towards higher levels of electronic adoption and move authorization management to a more exception-based process.”

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