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Contributor: The Future of Prior Authorization Under the Improving Seniors’ Timely Access to Care Act


Streamlining the prior authorization process can improve care accuracy and patient access to care, writes Siva Namasivayam, CEO of Cohere Health.

The process of securing advance approval from a health plan for a test, medication, or surgical procedure is often problematic for physicians and their patients. Prior authorization (PA) is still a largely manual process, which requires providers to fax forms and clinical notes to multiple health plans, each with its own authorization processes and coverage policies.

According to the American Medical Association (AMA), physicians and their staff spend an average of 13 hours each week completing PA requests. Ninety-three percent of physicians report that PA delays patient access to necessary medical care at least some of the time, and 82% of physicians report delayed approvals and authorization denials can lead patients to abandon their treatment plan.

Over the past 5 years, the push to mandate the implementation of electronic PA has gained new traction. Most recently, the US House of Representatives passed legislation that would affect the future of PA for Medicare Advantage (MA) plans. The Improving Seniors’ Timely Access to Care Act is intended to reduce providers’ administrative burden while improving the speed of patient access to necessary care.

Initially championed by the Regulatory Relief Commission, a group of national physician specialty organizations, the legislation amassed more than 340 legislative cosponsors and has a companion bill in the Senate. Given its bicameral, bipartisan support, the act is expected to reach the Senate floor later this year. Should the act pass, the legislation would then move to CMS, where the agency would implement the law via regulatory rulemaking.

Improving accuracy and timely patient access

The flurry of activity surrounding this legislation comes on the heels of an HHS report that concluded MA plans inappropriately denied 13% of PA requests for covered health care services. Reviewing claims from the same time period in 2019, the report also found that 18% of payment denials were for claims that met Medicare coverage rules and MA billing rules, which delayed or prevented payments for services already delivered.

The current legislation aims to address 3 of the most common causes of inappropriate denials cited by the report, including inadequate or missing clinical documentation, the use of extraneous criteria outside of Medicare rules, and human error. The legislation requires MA plans to carry out the following:

  • Implement electronic PA programs that adhere to newly developed federal standards
  • Issue real-time PA decisions for items and services that are identified as “routinely approved”
  • Issue accelerated PA decisions for all other services covered under Medicare Part C (ie, for all services that MA plans are mandated to cover)
  • Improve transparency by reporting to CMS on the items and services that require PA, the rate of approvals and denials, and the median and average time required for authorization review

Although the act has been endorsed by scores of health care associations, from the AMA to AARP, the legislation does not go far enough in ensuring the transparency and efficacy of utilization management. For years, the drive to fix PA has centered on automating health plans’ existing processes, as if expediency was the only missing ingredient in an otherwise sound process.

The truth of the matter is that utilization management, as it is currently constructed, misses opportunities to improve care quality and lower costs for patients, providers, and health plans. Digitizing PAs does indeed accelerate the submission of requests and the clinical review process; however, it does not transform PA into a more valuable tool for care management or for reducing unnecessary variations in care. It does not help health plans improve either the quality or the value of the care their members receive.

Influencing choices across an episode of care

If the new legislation passes in the Senate, health plans currently relying on manual or partially automated PA processes will need to invest in technology to comply with its requirements. This pivotal moment provides an opportunity for health plans to adopt technologies that support regulatory compliance and enable a more strategic approach to managing care.

In its current state, PA is a transactional experience: Each request for a service or medication is treated individually. Although an episode of care might require 3 diagnostic tests, 2 prescriptions, 1 surgery, and postoperative rehabilitation, each physician’s office operates alone in their separate requests for authorization. By taking a more holistic approach, health plans can better anticipate, manage, and approve a member’s needs across an episode of care.

PA data are one of the only signals of planned and impending health care encounters across multiple providers and specialists. Once structured, that data signal can be invaluable for early intervention and adjustment of a patient's care pathway. With greater interoperability, physicians and health plans can share patient-specific clinical data to contextualize a request in light of the patient’s condition and clinical history, giving health plans the opportunity to add true value to the authorization process.

Using artificial intelligence and machine learning, an intelligent utilization management platform can extract patient-specific data from a number of sources, including the electronic health record. Armed with the patient’s care history and evidence-based criteria, an intelligent platform has the ability to guide physicians toward high-value care choices that are likely to improve patient outcomes. For example, a physician might be prompted to select a gold-standard imaging modality instead of requesting multiple low-value tests, as the patient’s clinical data indicate the need for greater accuracy.

Instead of submitting several disconnected PA requests for one patient, physicians can get multiple services approved simultaneously for an entire episode, speeding patient access to the most appropriate care. When both the physician and the health plan have communicated and agreed upon an evidence-based care plan, utilization management has the ability to not only speed access to care, but to improve outcomes, reduce unnecessary testing, and elevate the standard of care across a population.

Sharing clinical criteria, policies, and timelines

Of course, transparency is the key to gaining provider buy-in for such an approach. While the new legislation specifies that MA plans be required to report on the timing and results of their electronic PA program to CMS, it is equally important for health plans to ensure full transparency for providers.

Back in 2018, 6 national advocacy associations—including America’s Health Insurance Plans, the American Hospital Association, and the AMA—issued a consensus statement detailing their ideas for fixing PA. Ensuring greater transparency and communication between health plans, providers, and patients is cited as necessary “to minimize care delays and clearly articulate prior authorization requirements, criteria, rationale, and program changes,” the report notes.

An intelligent authorization platform can easily exceed the legislative requirements for greater automation, transparency, and accelerated approvals by utilizing evidence-based clinical criteria that are clearly defined and referenceable for physicians. When physicians know in advance which services require approval and what documentation is necessary, the process will function more smoothly. Likewise, when physicians understand the clinical rationale behind a health plan’s policies—especially when they are derived from a national medical society’s standards of care—they are more apt to follow a high-value recommendation for a particular site, service, or test.

Since MA plans are committed to improving clinical outcomes and providing their members with access to the most appropriate health care services, for PA to function as a benefit rather than a roadblock, MA plans will need to broaden their perspective on how utilization management can best serve their members. Electronic PA is a good start, but it is not enough. To have a significant impact on the cost and quality of care, MA plans must adopt intelligent technology that gives providers meaningful support to help achieve the fastest and best possible outcomes for patients.

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