Innovation: The Key to Fixing Prior Auth


There are few things everyone in healthcare agrees on. But there is one area where payers, providers, physicians, and patients are all on the same page: prior authorization. Nobody likes it.

That message was driven home in an AMA survey that found massive dissatisfaction among doctors when it comes to prior auth (PA). Sixty-four percent of respondents reported waiting at least one business day for an authorization; 30% reported a delay of at least three days. Even more disturbing:

• 92% of respondents cited care delays associated with PA
• 78% report that PA can at least sometimes lead to treatment abandonment
• 92% say PA can have a negative impact on patient clinical outcomes

The evidence is clear: PA is a pain. But dislike it as we do, it’s not going away—so is there a way to help everyone dislike PA less?

Yes. Recent advances in decision support technology have been engineered to address the specific issues that physicians in the AMA survey are complaining about.

Let’s take a step back and examine what we have, what improvements are now available, and how and where we can make additional advancements in the near future.

The current PA system—if we can even call it that—is inefficient at multiple levels. It could delay appropriate care. It creates duplicative administrative work for providers, payers, and patients. It often requires multiple phone calls, faxes (Is the healthcare industry responsible for keeping the fax industry in business in 2018?), peer to peer discussions, payer secondary review, and appeals. It is exhausting to think about, much less to have to do.

How can the current system be improved? First, there are evidence-based, payer-and-provider-agnostic criteria available in contemporary formats that support the PA process. They provide a common vocabulary for, and promote a mutual understanding of, what is medically necessary.

This isn’t news. InterQual® from Change Healthcare has been doing this for more than 40 years, keeping pace with the evolution of decision support delivery.

Rather, key pain points with PA surround the administratively burdensome, manual processes. Why all the phone calls? Why does it take so long? Why does information from medical records need to be extracted, printed, and faxed? Why should providers whose requests are almost always approved have to go through the same process as those who have a lower approval percentage?

It has to do with people. One of the reasons for all the phone calls, the faxing, and the general back and forth, is that the traditional way to transmit information from provider to payer and back again is to have at least one person, and often two or more, involved in the PA process.

But today, that manual process can be streamlined through the use of provider portals by payers, using a Change Healthcare service called InterQual Connect™. This lets the provider’s office log in, answer questions as prompted, submit info as requested, and get an immediate approval or a deferred decision. No phones or faxes involved. A contemporary experience for both payer and provider.

Putting aside the issue of multiple portals and differing PA lists that make this challenging for providers, the use of InterQual Connect through a provider portal results in genuine time and cost savings. Moreover, providers such as hospitals can also submit directly through their care management systems into InterQual Connect, and direct information to the correct payer system.

That’s just one piece of the PA puzzle solved. Today we can automate even more of the process, using the now-ubiquitous EHR. Almost all of the information needed to process a PA request can be found in the EHR automatically, by software. If that information can be extracted and applied to criteria without human intervention, the approval determination is further accelerated.

Once the PA request is entered, a person doesn’t have to do anything more until the request is approved or pended. And given that many initial pended decisions are due to a lack of specific information that can be found in the medical record, retrieving data directly from that record will likely increase the number of approvals.

If that sounds like healthcare IT fiction, it’s not. That solution, InterQual AutoReview™, became generally available from Change Healthcare in March, and was demonstrated during HIMSS ’18 to throngs of providers. The general reaction? “Wow.” Now, hospital admissions using InterQual Criteria and InterQual AutoReview can automatically populate the medical necessity review, and then have InterQual Connect transmit it to the correct payer.

No phones or faxes required. The manual administrative requirements in the legacy PA “system,” with its attendant delays, duplicative workflows, and potential human errors, can be virtually eliminated. The result is a faster, more accurate decision based on evidence-fueled criteria.

Prior authorization will always be part of the care process. But it doesn’t have to be the part everybody loves to hate. Thanks to practical innovations such as InterQual Connect and InterQual AutoReview, it can be a faster, more efficient, and automated, process that physicians in the AMA survey can dislike less. A lot less.

Laura Coughlin is a Change Healthcare Vice President, for InterQual Development & Clinical Strategy