- The Workgroup for Electronic Data Interchange (WEDI) will be calling on the EHR vendor community for prior authorization improvement.
“Based upon the findings of the Prior Authorization Council (PAC) process, and in conjunction with the WEDI leadership, the PAC is endorsing a targeted effort to engage the EHR vendor community,” the non-profit user group stated in a recent industry white paper.
“The goal of the effort is to elicit a commitment on the part of EHR vendors to implement a single order entry workflow that supports the full automation of the industry prior authorization process. The workflow should be able to interface directly with payers and third-party intermediaries to create the capability for a standards-based digital dialogue between payers and providers.”
Payers use prior authorizations to ensure patients receive the most appropriate, cost-effective care. However, the medical management tool has increased the administrative burden on providers.
The American Medical Association’s 2018 Prior Authorization Physician Survey recently showed that 86 percent of providers describe the burden of prior authorizations as high or extremely high, and physicians and their staff are spending an average of almost two business days each week completing prior authorizations.
Furthermore, one in four physicians said prior authorizations result in a serious adverse event because of care delays and decision wait times.
Prior authorizations may seem like an issue between providers and payers. However, WEDI’s newly chartered Prior Authorization Council recently identified prior authorization workflow as a major challenge to alleviating the administrative burdens of the utilization management mechanism.
Specifically, the council of major payers, provider associations, health data exchange groups, and other stakeholders agreed that identifying best practices for prior authorization automation and changing the sequence of transactions were top opportunities for prior authorization improvement.
The adoption of electronic prior authorizations has been lagging across the industry. The most recent CAQH Index showed that the proportion of prior authorizations conducted manually actually increased to 51 percent in 2018, while just 12 percent of prior authorizations were fully electronic that year.
Providers and other stakeholders are experiencing workflow challenges because of a lack of integration of administrative and clinical data in provider systems, including EHRs, practice management systems (PMS), and other healthcare information systems (HIS), PAC found.
“Despite a high degree of consolidation in recent years across the EHR/PMS/HIS vendor space, the software that supports clinical care delivery and the associated documentation of care, and the software that supports the revenue cycle management activities, is not highly integrated,” the white paper stated.
“Even in major system vendors, the degree of internal integration that would allow workflows to be developed that easily integrate clinical and administrative data across the software has lacked the investment to support end-to-end automation of prior authorization between payers and providers.”
Adding to the problem is the fact that slow implementation of technology by payers for utilization management strategies led to a lack of system, data, and process integration at insurance companies.
“Native physical and logical connectivity between core claims processing systems, EDI front ends, proprietary payer portals, and the technology employed by third-party quality and utilization management vendors falls far short of any consistent capability across the industry to support standards-based, end-to-end automation,” the paper explained. “The challenge to burden reduction on both payers and providers is further complicated by the fact that many payers still require manual handling and human review as part of the PA [prior authorization] process.”
The healthcare industry needs a machine-based workflow to address the administrative burden of prior authorizations, particularly for providers, the council advised.
“The absence of focused work directed at designing a workflow that implements full machine-to-machine automation of the prior authorization process from the point-of-care episode to determination of benefit coverage, with an end-to-end audit trail, means that the most time-consuming part of provider administrative burden is not being addressed,” the paper stated.
Chief among provider complaints about prior authorization burden is the work needed to communicate with payers. Providers find it difficult to identify whether a prior authorization is required during the patient encounters.
Additionally, providers struggle to determine the documentation payers require for a prior authorization decision.
Health IT vendors are working on solving the provider challenges. For example, health data standard groups using X12, HL7, and FHIR have been developing tools to connect payers and providers in real-time through technology and the EHR.
However, the council pointed out that stakeholders are attempting to solve the prior authorization challenges separately.
“This lack of focus on the vendor-based workflow automation from the major stakeholder organizations represents a significant gap in coordinated industry effort to solve an issue that effects all stakeholders,” the paper stated.
PAC recommended the establishment of a working group dedicated to settings expectations for EHR, practice management system, and other health IT vendors.
“These expectations should clearly recognize that the primary prior authorization burden on the industry lies in the lack of full end-to-end, machine-to-machine automation of the process,” the council advised. “This working group would be charged insuring the development of a reference architecture that coordinates the work of all the stakeholder groups to achieve a result that can be characterized as ‘Single Action Order Entry.’”
Single action order entry involves providers determining prior authorization requirements through the EHR at the time of the patient encounter. By inputting requested services, the provider triggers a workflow within the EHR. The system then connects with payers to find if an authorization is required and what documentation is needed.
If an authorization is required, the EHR workflow gathers the necessary data to support a Health Care Services Review Request for Review and Response and submits the response to the payer either directly or through an intermediary service.
Payers can then respond in real-time and the EHR will translate the approval, denial, or request for more information, so providers understand the decision.
PAC plans to leverage the data standards and exchange techniques used by HL7, X12, and FHIR to connect the multiple stakeholders and technologies.