Making Automated Prior Authorization Faster and Provider Adoption Better

Even as COVID-19 cases were spiking around the country in 2020, placing a huge burden on the U.S. healthcare system, physicians struggled to get approvals from their health plans for prior authorizations (PAs). The resulting delays caused some patients to abandon treatment plans.

Brian Covino, M.D.

This isn’t just one physician’s opinion. It’s what physicians told the American Medical Association in a newly released survey about the impact of the pandemic on medical doctors and their patients.

The numbers are sobering: 69% of 1,000 practicing physicians surveyed in December 2020 reported that health insurers had either reverted to pre-pandemic PA policies or never relaxed these policies. Only 1% of responding physicians said their health insurers maintained relaxed requirements through the end of 2020, when the U.S. health system was buckling under the strain of record numbers of COVID-19 cases.

Unfortunately, the manual-based PA processes used for years by health insurers can create a bureaucratic nightmare in the best of times. The AMA survey shows that 94% of physicians report having experienced care delays while waiting for health insurers to authorize necessary courses of treatment.

Those delays come at a real cost. Ninety percent of physicians said PA requirements have a negative effect on patient clinical outcomes, while 30% said the requirements have led to a serious adverse event for a patient in their care. These include patient hospitalization (reported by 21% of physicians), life-threatening events or interventions to prevent permanent impairment or damage (18%), and permanent disability or death (9%).

Striking as these numbers are, the AMA report essentially summarizes what everybody already knew: A significant number of physicians and patients are impacted by delays related to PAs. When unnecessary delays in approving medical care results in harm to patients, something has to change. Archaic PA processes should be streamlined to reduce delays or disruptions to the delivery of healthcare services.

The good news is that electronic prior authorizations (ePAs) already exist to reduce the wait time for PA approvals from health plans. A new report by the trade group America’s Health Insurance Plans (AHIP) on the results of a yearlong initiative to assess the impact of ePA concludes the median time between submitting a prior authorization request and receiving a decision from the health plan was reduced from 18.7 hours to 5.7 hours, a reduction of 69%.

It’s clear why ePA saves time for physicians and their staff. According to the AHIP survey, 34% of all survey respondents reported fewer phone calls, 38% reported fewer faxes coming in and going out, 42% reported less time spent on phone calls, and 41% reported less time spent composing faxes and transmitting them.

Why automated PAs are the solution

Automating prior authorizations through digital technology makes the process even faster and more efficient while decreasing the chances of adverse outcomes due to delays. Such a technology solution must be user-friendly in design and able to instantaneously approve prior authorizations. For example, physicians now typically must access multiple web portals to submit prior authorization requests.

An efficient automated PA process consolidates requests within a single portal. To improve provider adoption, the emphasis here is on efficiency, because if processes (even electronic) are just as slow or slower than traditional methods, more providers will revert to the path of least resistance--the fax machine.

Imagine physicians being able to receive a prior authorization approval at the point of care while they’re still with their patients, minutes after submitting a request. This presents an ideal opportunity for the physician to collaborate with a patient on a treatment plan, improving the chances that the patient will adhere to that plan. Now contrast that with the more common current scenario in which a physician’s office has to call a patient days after an appointment to inform them of the insurer’s decision regarding authorization.

Not only does fully automating the PA process eliminate disruptions to the care continuum that frustrate physicians and patients while undermining treatment, it frees up time for physicians and staff to spend on higher-value activities such as patient care, safety and support. To support this claim, the AMA survey estimates that physicians and their staff currently spend 16 hours a week completing PAs using traditional methods.

If that’s not enough incentive to adopt automated electronic PA, consider the competitive advantages for providers and payers of a rapid PA process. Patients and members would be more satisfied and loyal to their care plans, with potentially better outcomes, while physicians and office staff would have higher adoption rates leading to less frustration.

CMS passed a final rule in January 2021 that puts pressure on payers to provide standardized application programming interfaces (APIs) to enable payer-to-provider sharing of PA data. While this rule has received some support from provider and hospital groups, the American Hospital Association (AHA) and others have rightly criticized it as being too generous to payers. Under the CMS rule, payers would have up to seven days to review standard PA requests and 72 hours for urgent cases.

The new CMS rule is under review by the Biden Administration and has yet to be enacted. Given how ineffective it would be in reducing PA delays (up to seven days!), it would not be surprising to see CMS revise something along the lines of what the AHA proposes, which is 24 hours for urgent needs and 72 hours for review of standard cases. Most recently, the proposed Improving Seniors’ Timely Access to Care Act would encourage or require real-time decisions on Medicare Advantage authorization requests—a stipulation that would force plans to enable instant, automated clinical reviews.

COVID-19 provided a reminder that the manual healthcare PA process still widely used can’t scale to meet demand. This doesn’t bode well for our ability to handle large populations such as Medicare and Medicare Advantage members. We can meet this challenge only if healthcare stakeholders are willing to work together for greater adoption of automated PAs with the added benefits to and collaborative opportunities for patients, providers, payers, and our entire healthcare system.

Brian Covino, M.D., is chief medical officer at Cohere Health. Previously, he practiced orthopedic surgery for over 25 years.