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Author’s Corner


In this white paper, Randall Davis, Senior Director of Client Operations, discusses the challenges of Prior Authorization (PA) processes in healthcare, emphasizing the burdens faced by physicians. He discusses conflicting perspectives between health insurance plans and physicians, emphasizing the need for automation to streamline PA processes and enhance patient outcomes.

Please click on the video to the right to learn more about the author, hear his insights on this white paper, and learn what motivated him to write about the prior authorization processes in healthcare.

To discuss this white paper in detail, please contact Randall using the information provided at the bottom of the page.

Automating authorization for care payment to providers reduces the administrative burden on physicians, allowing them to spend more time with their patients for better clinical outcomes. But system integration across thousands of payers and providers is a frightful barrier. Here, we address critical stakeholder needs, map interoperability requirements, and suggest practical implementations to accelerate care.

The Prior Authorization


Health insurance plans assure medical necessity and safety of procedures and pharmaceuticals for their members while keeping healthcare affordable. The process they use to meet this need, the Prior Authorization (PA), frustrates physicians. It is a time-consuming burden resulting in worse patient outcomes and higher costs.

Quality, Safety, and Affordability


America’s Health Insurance Plan (AHIP) members direct policies for reviewing high-cost procedures and pharmaceuticals through their PA processes. They cited these top program objectives in the 2022 member survey:1

  • Improve Quality Through Evidence-Based Care
  • Protect Patient Safety
  • Reduce Unnecessary Spending

However, American Medical Association (AMA) physicians showed a markedly different assessment in their 2022 survey.2

quality-safety-and-affordability

They describe Prior Authorization criterion that:

  • Is only sometimes evidence-based
  • Delays patient care
  • Causes patients to abandon care
  • Produces adverse effects from denials
  • Results in higher overall cost of care

Figure1: AHIP and AMA member Prior Authorization Criteria Rating 1,2,3

These survey results present strikingly different views of reality between payers and providers. PA administrative burden prevents collaboration and problem-solving at the point of care because physicians see significant, negative patient outcomes from the current process.

Physicians need clear visibility into coverage and quick commitment for the clinical plan. Tweaks to manual processes have yielded little improvement. Perhaps, with an automated process, physicians could quickly understand which procedures and pharmaceuticals are covered by a patient’s medical plan and direct care with an appropriated treatment option.

The Centers for Medicare & Medicaid Services (CMS) considered the burden on both providers and payers, searching for a structure that can improve patient outcomes. It weighed in with an automated solution, proposing regulations for January 1, 2026 implementation.4 Impacted payers would be required to return prior authorization decisions to providers within 72 hours. Cheering, but urging them to go faster, nearly 300 legislators signed a supportive letter to the HHS Secretary but shortening the decision window to 24 hours.5

The CMS Solution


CMS proposes reducing burdens on payers, providers, and patients by streamlining PAs with processes that enable electronic prior authorization. Ultimately, it believes reduced provider burden through automation will mean more time with patients.4

CMS recommends Application Programming Interfaces (APIs) for interoperability between provider and payer systems. For a practical implementation, CMS tapped the HL7 FHIR Da Vinci project, a private sector community of payers, providers, and vendor organizations addressing the needs of the Value-Based Care community.

The Da Vinci community tackled three business processes for approving treatment plan payment at the point of care.

  • First, payers must give providers real-time data access to discover approval requirements and rules.
  • Second, payers must create electronic versions of administrative and clinical requirement documents that support the provider’s workflow.
  • Last, providers must be able to formally request authorization, embedding all supporting clinical information, and receive authorization notification within three days. 4

Three APIs on FHIR


Success requires an API for each business process. The Da Vinci team wrote implementation guides, model software, and test suites that prove out the details. Specific use cases consider how to bridge legacy systems of industry participants and how to interface between Electronic Health Record (EHR) systems, payer systems, and clearing house aggregators using Fast Healthcare Interoperability Resource (FHIR) standards.6

Per CMS, all covered participants must implement these APIs to interface with existing systems:

1. Coverage Requirements Discovery (CRD) API:

Enable real-time discovery of payer approval requirements and rules. On behalf of the provider, the EHR system sends patient diagnoses and desired procedures/pharma to the payer system. The payer’s system responds with a list of covered items and services for which prior authorization is required for this specific insurance plan member.

2. Document Template and Coverage Rules (DTR) API:

Enable the provider to obtain and fill out an administrative and clinical requirements document. The provider’s EHR requests a template document from the payer system for the chosen treatment plan. The payer’s system responds with a customized template of required data. The provider uses their EHR to complete the template using Clinical Query Language to satisfy dependencies.

3. Prior Authorization Support (PAS) API:

The provider’s EHR sends a formal request for approval accompanied by the completed DTR. The payer reviews and approves. Since all required parameters were well documented up front, approval can be processed in real time at the point of care.

fhir

Figure 2: HL7 FHIR Da Vinci API Implementation Components

Building and integrating these system interfaces demands hard work behind the scenes. Collaborating with Da Vinci, several top payers, providers, clearing houses, and HIT vendors are already developing solutions for testing together.

For payers, CMS stipulates "Provider Access” to the APIs for handling requests from provider systems. This will create industry-wide functionality for providers to send and receive authorization transactions. However, for smaller payers and most providers, this represents a huge technological transition for regulatory compliance in a very short time.

Integration Ahead


Health Information Technology (HIT) vendors will fill technology gaps for many payers and providers with integration solutions. As an indication of the problem at hand, we expect many legacy payer systems to be unable to handle direct API messages from providers.

HIT vendors, clearing houses, and professional services firms can shield their payer clients from complexity by exposing a Provider Access API to health systems on their behalf. To make the transition easy for payers, they’ll transmit required data from providers in real time to and from the payer’s claim management system. If they forestall legacy system rewrites on advice from the Da Vinci community, they may patch together compliance solutions like API gateways, X12 messages, secure email, robotic process automation, or even web portals and staff.

On the provider side, HIT vendors will present modern “CDS Hooks” interfaces to the EHR workflow, linking requests to a CRD API for payer systems. For older EHRs, HIT vendors can present a popup window to clinical staff, collect the required PA discovery data, transmit to payers using the CRD API, and present the result back to the provider in a convenient system message.

Similarly, for the DTR and PAS API transactions, HIT vendors can simplify the provider role with integration. On the provider’s behalf, they can request the PA template, return the template to the provider, securely transmit the completed form with clinical notes to the payer, and return the approval.

Better Patient Outcomes


Using prior authorization automation, physicians can assure the medical necessity and safety of treatment procedures and pharmaceuticals while keeping healthcare affordable. Automation means more physician time with patients, accelerated treatment, and better clinical outcomes.

Solve tough prior authorization problems for your organization by challenging the integration consultants at Vee Healthtek to implement process optimization, system integration, and reliable automation solutions.

Sources:

1. AHIP 2022 Survey on Prior Authorization Practices and Gold Carding Experiences
https://www.ahip.org/resources/ahip-2022-survey-on-prior-authorization-practices-and-gold-carding-experiences

2. Prior Authorization AMA Physician 2022 Survey
https://www.ama-assn.org/system/files/prior-authorization-survey.pdf

3. Key Results of Industry Survey on Prior Authorization, AHIP 2019,
https://www.ahip.org/documents/Prior-Authorization-Survey-Results.pdf

4. CMS Advancing Interoperability and Improving Prior Authorization Processes – Proposed Rule
https://www.healthit.gov/sites/default/files/facas/2023-02-08_CMS_Presentation.pdf

5. Improving Seniors’ Timely Access to Care, Senate and House lawmakers’ letter to HHS
https://www.aans.org/-/media/Files/AANS/Advocacy/2023-News/June/SenateMAPALettertoCMS62123FINAL.ashx

6. HL7 FHIR Da Vinci Project
http://www.hl7.org/about/davinci/index.cfm

Randall Davis

Meet the Author

Randall Davis - Senior Director Client Operations

Randall Davis' entire career in complex systems has been focused on solving practical problems in service development and operations. Through two decades in software engineering, finance, and healthcare, he deployed critical infrastructure for process performance and reliability on a collapsing cost curve. Since 2013, Randall has dramatically improved healthcare revenue efficiency through technology and process innovation.