AHIP, insurers to test IT to speed prior authorization process

With prior authorization posing a significant pain point for providers, several health insurers and the organization representing them are starting an initiative to improve the process.

With prior authorization posing a significant pain point for providers, several health insurers and the organization representing them are starting an initiative to improve the process.

The approach will lean on information exchange technology to accelerate the often-ponderous process by which providers obtain permission and payment guarantees for prescribing care to patients.

On Monday, America’s Health Insurance Plans (AHIP) and several member health insurers pilot tested the program, called the Fast Prior Authorization Technology Highway (Fast PATH), to improve the process. The initiative will rely on technologies of Availity and Surescripts to accelerate the exchange of prior authorization requests, responses and information exchange.

Participating in components of Fast PATH are health insurance providers that collectively cover more than 60 million Americans—Anthem, Blue Shield of California, Cambia’s affiliated health plans, Cigna, Florida Blue, and WellCare.

The prior authorization process, which is heavily dependent on manual processes, is a headache for provider organizations. In fact, facilitating the process of gaining health plans’ approval for medical treatment has grown to be one of the biggest frustrations for physicians in group practices, said Robert Tennant, director of health information technology policy for the Medical Group Management Association in October at its annual conference.

Some 83 percent of respondents to a recent MGMA survey cited prior authorization for medical services as their No. 1 burden, Tennant said. And, another survey suggested that 90 percent of 1,000 physician respondents said the process is getting worse.

Electronic approaches to gaining prior authorization are becoming increasingly available to physicians, but most still use manual processes to request prior authorizations, despite the common availability of online submission portals. AHIP data suggest that 46 percent of prior authorization requests are submitted by fax, and 60 percent require a telephone call. Fast PATH aims to employ technology in the physician’s office to improve connections between insurers, physician offices and other care settings.

“When patients do better, we all do better,” said Matt Eyles, president and CEO of AHIP. “Patients should receive the right treatments and medications at the right time in the most effective and efficient way. That’s why we’re committed to reducing unnecessary burden, increasing patient satisfaction and improving quality and outcomes.”

For prescription medications, Fast PATH would use Surescripts technology to make information available to physicians while the patient is still in the office. With the initiative, when a doctor prescribes a medication through an electronic health record (EHR), they can immediately access the patient’s pharmacy benefits, know whether the specific medication requires prior authorization and have the information to choose an alternative treatment that is clinically equivalent but more cost-effective and does not require prior authorization.

Also through the EHR, the doctor will also have access to the patient’s out-of-pocket cost for each drug, so the patient will know what to expect to pay when picking up the medication at their pharmacy.

For enabling prior authorization for medical and surgical procedures, Fast PATH would use Availity technology to offer physicians and surgeons access to a multi-payer portal to simplify prior authorization requests. The portal would aim to enable easier communication and faster approvals from insurers.

If prior authorization is required, the provider can submit the necessary information through the Availity portal to fulfill the request, avoiding time-consuming phone calls and interruptions to patient care. The health insurance provider then can review the information, make a determination based on the patient’s coverage and treatment evidence, and send a response through the portal.

AHIP will assess the program through an independent not-for-profit research organization. AHIP will use the results to work with physicians, hospitals, care providers and other stakeholders on the development of interoperability and electronic prior authorization.

The goal is to offer a voluntary approach that is scalable and can be highly integrated with existing electronic health records systems.

Prior authorization remains important for health insurers, says Kate Berry, senior vice president of clinical affairs for AHIP. “A lot of studies that show that there are variations in treatment and potential misuses of care. The opioid crisis is an example of that,” Berry says. “Medical management (through prior authorization) is one way to do that and is an important tool for patients. It can be improved, but it must be used to protect patients and promote evidence-based care.”

Health plans use prior authorization “pretty sparingly,” Berry contends, saying it comes into play in only 15 percent of cases.

As health insurers roll out initiatives to test ways to speed prior authorization, the goal is to do so through standards-based solutions that will be widely scalable and includes participation of providers and the technology they’re currently using, she adds.

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