HIMSS 2017: Prior authorization flaws require collaborative response

A multi-stakeholder conversation about the burden of prior authorization requirements offered a consensus that something has to change with these policies, but the parties could not offer a silver bullet on how the process can improve.

The HIMSS 2017 session featured speakers from the American Medical Association (AMA), the Council for Affordable Quality Healthcare (CAQH) and the Healthcare Administrative Technology Association, among others. All groups involved indicated they have surveyed providers and healthcare professionals on the headaches with prior authorization (PA). Solving those issues, they agreed, would require an industry-wide effort

For example, AMA Senior Policy Analyst Heather McComas said in conducting surveys about strategies to reduce administrative burden, physicians indicated several problems with PA. Beyond concerns that it delays care for patients, practices said staff members spend an average of 37 hours per week on PA requests, with one-third of AMA members surveyed saying they have employees whose sole job is handling PA.

“I think you all can agree there are a lot of better ways for people to spend their time,” McComas said.

After conducting the survey, the AMA and others group released a 21-point plan for changing when insurers require pre-approval for certain drugs, treatments and advices. Among the top concerns repeated by McComas and others at the session was a focus on clinical validity—making sure the requirement for prior authorization isn’t solely based on how much a treatment costs.

How those requests are processed may be the biggest barrier for efficiently incorporating PA into a practice’s workflow. Echoing comments from McComas, Liz Hartley-Smith, clinical data exchange manager at Blue Cross Blue Shield Louisiana (BCBSLA), said most of these requests are still sent by phone or fax, resulting in duplicative efforts related to the same patient, wasting time and effort.

To alleviate some of these burdens, BCBSLA is rolling in an authorization portal, allowing providers to enter information and receive “an immediate notification” of whether the PA was approved.

“So far, our providers love it. Whatever option we’ve given them, they’ve loved having the option,” Smith said. “They love not having to mail us huge boxes of medical records."

Improvements still need to be made, Smith said. The portal will support the standard electronic PA transaction, known as a 278, though Smith noted there isn’t a great demand for it yet, and she added that its working on automating record requests. The goal is to decrease the instances of someone having to manually review any patient’s records, resulting in faster responses to PA requests.