Why It’s Time for Clever Prior Authorization

Alina M. Czekai, MPH, VP of Strategic Partnerships at Cohere Well being

In September, the U.S. Home of Representatives handed a invoice supposed to speed up affected person entry to care by streamlining prior authorization (PA) processes. The Improving Seniors’ Timely Access to Care Act mandates the adoption of digital PA for Medicare Benefit (MA) plans and requires plans to supply higher coverage transparency, approval charges, and rationale for denials.  

With appreciable bipartisan help, the laws has gained endorsements from notable main healthcare commerce organizations, together with the American Medical Affiliation, the American Hospital Affiliation, the American Academy of Orthopedic Surgeons, and AARP. If the invoice passes within the Senate as anticipated, it may very well be regulation in early 2023.

Traditionally, efforts to treatment the PA course of have centered on automating well being plans’ current processes – as if effectivity have been the one lacking ingredient in an in any other case sound course of. The laws, whereas designed to assist drive higher PA effectivity, units a basis for payers to do rather more – together with decreasing unwarranted care variations and higher aligning with value-based care fashions to extra holistic, longitudinal care and driving evidence-based care paths – all of which may result in higher, quicker care. 

It’s true that PA is time-consuming and fraught with administrative burdens for physicians and employees – usually requiring faxing and even the mailing of scientific notes. On the well being plan facet, some make use of massive name facilities to scale back the executive burden on their employees. A current AMA survey revealed that physicians and their employees spend a mean of 13 hours every week completing PA requests. The survey additionally discovered that 93% of physicians say that PA delays affected person entry to vital medical care, and 82% of physicians report that PA processes can typically result in therapy abandonment. 

Certainly, digitizing prior authorization processes does speed up the submission of requests and the following scientific assessment course of. It doesn’t, nonetheless, by itself remodel PA right into a extra beneficial software for care administration or for decreasing pointless variations in care. So a beneficial alternative for well being plans to additional enhance both high quality of care is missed. 

If the pending laws turns into regulation, well being plans utilizing handbook or partially automated PA processes will have to put money into expertise to conform. This pivotal second gives a chance for well being plans to undertake superior applied sciences that not solely guarantee regulatory compliance however allow extra strategic care administration. It’s time for clever utilization administration, starting with prior authorization.

Utilizing synthetic intelligence and machine studying, an clever utilization administration platform can extract patient-specific knowledge from a number of sources, together with the digital well being report. Armed with the affected person’s care historical past and evidence-based standards, an clever platform can information physicians towards care decisions which can be doubtless to enhance affected person outcomes. And fairly than submitting a number of disconnected PA requests for one affected person, clinicians can get a number of companies accepted concurrently – spanning a whole episode and successfully dashing affected person entry to essentially the most applicable care.

An clever authorization platform can simply meet the legislative necessities for higher automation, transparency, and accelerated approvals by using evidence-based scientific standards which can be clearly outlined and referenceable for physicians. 

The only real focus of prior authorization ought to be the affected person – higher outcomes, higher affected person expertise, and a extra clinically applicable care path. Digital PA is definitely start line, however it’s not sufficient. To have a major affect on the associated fee and high quality of care, healthcare ought to undertake clever expertise that offers suppliers significant help to assist obtain the quickest and absolute best outcomes for sufferers.

About Alina M. Czekai, MPH

Alina M. Czekai, MPH, is the Vice President of Strategic Partnerships at Cohere Health, a collaborative utilization administration expertise vendor. Previous to becoming a member of Cohere, she was a senior advisor to Administrator Seema Verma on the Facilities for Medicare & Medicaid Companies. LinkedIn – https://www.linkedin.com/in/alinaczekai/