Hear insights from our CEO
I had the honor of being asked to participate at NAHAM’s Prior Authorization Roundtable in October 2022 bringing together stakeholders from provider, payer, and vendor communities in an effort to stimulate discussions around potential solutions.
Having spent time as a front-line provider requesting prior authorizations for my patients, a value-based healthcare researcher developing and implementing evidence-based pediatric surgical care pathways, and now as an entrepreneur looking to build technology infrastructure to automate prior authorizations, I found this discussion interesting from a unique vantage point of understanding all 3 sides.
Several key points were highlighted:
- Payers are frequently constrained by either CMS-defined coverage guidelines (NCDs – national coverage determinations, LCDs – local coverage determinations) and/or by contractual decisions made by employers in their sponsored plan choices.
- Despite a desire to have standardized clinical guidelines across all payers, plans and their medical directors consider this as an area of competitive differentiation and/or a grey area where medical judgment is applied to the best of their abilities and within compliance with NCQA and URAC requirements.
- There is frustration on the part of payers on what is considered unnecessary care requests that are not justified by evidence-based guidelines and literature.
- For providers, each payer has its set of opaque prior authorization/pre-certification rules for different service lines, which all seem to be continuously changing. Maintaining and managing all the different, shifting payer rules seems to be a Sisyphean task, one certainly not capable of being supported by today’s EHRs and practice management systems.
- There is a need for a national clearinghouse for prior authorization transactions. One that can seamlessly integrate into EHRs/PMS and act as a single interface for all payer-prior authorization transactions. Most agreed that the existing x12 278 standard does not adequately cover all the data elements necessary in a prior authorization transaction. This is why there is little to no adoption outside of a limited set of notices of admissions workflows today.
There were several ideas that I took away from the conversation that I feel merit additional discussion:
- Transparency on authorization requirements – a standard, machine-readable format from all payers to provide their established guidelines around specific sets of services. This would include info on ICD-10, CPT/HCPCS/RxNorm, as well as any delegated benefit manager (eg AIM, NIA, eviCore, etc) and specific product information. This would allow providers to develop and maintain rules that can help better guide prior authorization requests and eliminate unnecessary errors/work
- List of which services do NOT require authorizations (“no auth required”) – this would save a tremendous amount of time, cost, frustration, and delay for patients waiting for care. This is an area payers can easily agree to as there is substantial cost generated from unnecessarily submitted prior authorizations, which still require review for compliance reasons.
- “Open enrollment” period for payer authorization rule changes – create specified windows/periods of time during the year when payers can make changes to prior authorization rules. This would help address the highly variable rule changes that frequently do not get recognized by provider teams.
- A national clearinghouse for prior authorization data exchange. This is the holy grail and what Voluware has been methodically building with our Valer all-payer, all service line payer network. One place to 1) seamlessly integrate with EHRs/PMs, 2) comprehensively cover across legacy fax forms and web portals, and 3) rapidly update and maintain changing payer rules.
Certainly, we all hope that NAHAM and other organizations can keep the momentum going when it comes to offering practical, workflow-driven solutions to prior authorizations. I hope that the spirit of collaboration and interest in real-world validation of innovative solutions continues.