By: Pramod Naik, Principal Consultant - Healthcare, LTI

Prior Authorizations (PA) is a process in Healthcare where providers are required to take approval from the Insurer before performing surgeries, diagnostic tests, procedures, and certain prescriptions to avoid potential unnecessary, inappropriate or unsafe medical treatments.

For providers, it presents significant administrative and financial burdens. They juggle multiple health plan requirements and processes to submit a request, identify additional information, and wait for a final response. This process can take hours, days, and sometimes weeks before the request is ultimately approved or denied.

Prior Authorization today – a broken flow
A PA request can be fully electronic (HIPAA EDI 278 transaction) or partially electronic (Web portal or IVR transaction). As per the Council for Affordable Quality Healthcare (CAQH) 2018 index, 12% PA requests were fully electronic, 36% were partially electronic and 51% of the authorization request done were fully manual. As seen, most are often processed manually through phone, email or fax, where the plan requires clinical information from the provider on a standard authorization request form.

Once the prior authorization request is received by the Health Plan, it goes through an internal review, rather than an intelligent automated process.

Improving the workflow

“The future of prior authorization is real-time – prior authorization should be a discussion, not a transaction,” says Robert M. Tennant, Director of Health Information Technology Policy and the Medical Group Management Association (MGMA). “If we can automate that discussion, it can really save time for physicians and improve patient care.”

Technology is paving the way to automate this manual intensive process.
The new approach would trigger a request to a Document Requirement Lookup Service (DRLS) from a providers Practice Management System (PMS) integrated with Electronic Health Record (EHR) when a provider places an order.

The Da Vinci project, convened by HL7 – a healthcare standards development organization, has piloted the DRLS program for exchange of information between providers and private health plans using Fast Healthcare Interoperability Resources (FHIR).

The DRLS is based on following two use cases:

• Coverage Requirements Discovery (CRD) is primarily for providers to check if a procedure requires a prior authorization and/or documents proving the current medical condition
• Document Template and Coverage Rules (DTR) is for providers to request and receive required documents, templates and authorization rules required by health plans and Medicare Fee for Service (FFS) plans.

This new process would offer a clinical template to providers, outlining what is needed to justify the ordered intervention and prove the medical necessities.

Evolving operating standards and infrastructure rules
CAQH has released the new PA operating standards and Infrastructure rules. The Phase IV infrastructure rules define the connectivity methods, request receipt acknowledgment, required response time to ensure that PA information is shared in an organized and trusted way following a consistent method. The Phase V operating rules define standardization of data content which includes procedure codes, laboratory testing LOINC codes, medical service, devices and medications.

As per CAQH index, adopting to this new automated electronic Prior Authorization (ePA) workflow process will result in ~70% effort reduction and tremendous cost savings per transaction to both provider and payer. The Healthcare industry will soon experience reduction of administrative waste, easing financial burdens as a result of end-to-end automation in this new governed workflow-based PA process.