Innovation the Key to Fixing Prior Authorization

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

That message was driven home in an AMA survey that found massive dissatisfaction among doctors with regard to PA. An overwhelming 85% of respondents describe the administrative burden associated with PA as “high or extremely high.” Even more disturbing:

• 94% of respondents cited care delays associated with PA
• 79% report that PA can lead to the abandonment of treatment
• 30% say that PA has led to a serious adverse event for a patient in their care

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?

Luckily, there is. Recent advances in decision support technology 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 available, and how and where we can make additional advancements in the near future.

The inefficiency of the current PA process can be a contributing factor in the delay of appropriate care. It creates duplicative administrative work for providers, payers, and patients, and it usually requires multiple phone calls, faxes, peer-to-peer discussions, payer secondary review, and appeals.

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.

Of course, the existence of such criteria isn’t news. Change Healthcare’s InterQual^® portfolio has been providing evidence-based criteria for more than 40 years, keeping pace with the evolution of clinical decision support delivery.

Clearly, criteria alone can’t revolutionize the PA process. The key pain points with PAs center on 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 processes as those who have a lower approval percentage?

One of the reasons for all the back-and-forth phone calls and faxing is that the current information flow is not automatic; it’s utterly dependent upon people.  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 solution called InterQual^® Connect. This solution 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 are required; it’s a contemporary experience for both payer and provider.

The use of InterQual Connect through a provider portal can result in genuine time and cost savings. Alternatively, hospitals can submit directly through their care-management systems into InterQual Connect and direct information to the correct payer system automatically.

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 automatically found in the EHR via software. If that information can be extracted and applied to criteria without human intervention, the approval determination can be further accelerated.

Once the PA request is entered, a person doesn’t have to do anything more until the request is approved or pended. Given that many initial decisions are marked as pending due to 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 science fiction, it’s not. That solution, InterQual^® AutoReview, is currently live at an expanding number of customer sites. 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.

The time-consuming manual administrative requirements required for PA—with their attendant delays, duplicative workflows, and potential human errors—can be virtually eliminated. This enables 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—one that physicians can rely on to provide what they need as quickly as possible. 

Laura Coughlin is the vice president of Clinical Innovation and Development at Change Healthcare.