Why It’s Time for Intelligent Prior Authorization

Alina M. Czekai, MPH, VP of Strategic Partnerships at Cohere Health

In September, the U.S. House of Representatives passed a bill intended to accelerate patient access to care by streamlining prior authorization (PA) processes. The Improving Seniors’ Timely Access to Care Act mandates the adoption of electronic PA for Medicare Advantage (MA) plans and requires plans to offer greater policy transparency, approval rates, and rationale for denials.  

With considerable bipartisan support, the legislation has won endorsements from notable leading healthcare trade organizations, including the American Medical Association, the American Hospital Association, the American Academy of Orthopedic Surgeons, and AARP. If the bill passes in the Senate as expected, it could be law in early 2023.

Historically, efforts to remedy the PA process have focused on automating health plans’ existing processes – as if efficiency were the only missing ingredient in an otherwise sound process. The legislation, while designed to help drive greater PA efficiency, sets a foundation for payers to do much more – including reducing unwarranted care variations and better aligning with value-based care models to more holistic, longitudinal care and driving evidence-based care paths – all of which can lead to better, faster care. 

It’s true that PA is time-consuming and fraught with administrative burdens for physicians and staff – typically requiring faxing and even the mailing of clinical notes. On the health plan side, some employ large call centers to reduce the administrative burden on their staff. A recent AMA survey revealed that physicians and their staff spend an average of 13 hours each week completing PA requests. The survey also found that 93% of physicians say that PA delays patient access to necessary medical care, and 82% of physicians report that PA processes can sometimes lead to treatment abandonment. 

Indeed, digitizing prior authorization processes does accelerate the submission of requests and the ensuing clinical review process. It does not, however, on its own transform PA into a more valuable tool for care management or for reducing unnecessary variations in care. So a valuable opportunity for health plans to further improve either quality of care is overlooked. 

If the pending legislation becomes law, health plans using manual or partially automated PA processes will need to invest in technology to comply. This pivotal moment provides an opportunity for health plans to adopt advanced technologies that not only ensure regulatory compliance but enable more strategic care management. It is time for intelligent utilization management, beginning with prior authorization.

Using artificial intelligence and machine learning, an intelligent utilization management platform can extract patient-specific data from several sources, including the electronic health record. Armed with the patient’s care history and evidence-based criteria, an intelligent platform can guide physicians toward care choices that are likely to improve patient outcomes. And rather than submitting several disconnected PA requests for one patient, clinicians can get multiple services approved simultaneously – spanning an entire episode and effectively speeding patient access to the most appropriate care.

An intelligent authorization platform can easily meet the legislative requirements for greater automation, transparency, and accelerated approvals by utilizing evidence-based clinical criteria that are clearly defined and referenceable for physicians. 

The sole focus of prior authorization should be the patient – better outcomes, better patient experience, and a more clinically appropriate care path. Electronic PA is surely a good starting point, but it is not enough. To have a significant impact on the cost and quality of care, healthcare should adopt intelligent technology that gives providers meaningful support to help achieve the fastest and best possible outcomes for patients.

About Alina M. Czekai, MPH

Alina M. Czekai, MPH, is the Vice President of Strategic Partnerships at Cohere Health, a collaborative utilization management technology vendor. Prior to joining Cohere, she was a senior advisor to Administrator Seema Verma at the Centers for Medicare & Medicaid Services. LinkedIn – https://www.linkedin.com/in/alinaczekai/