Five Trends Disrupting the Prior Authorization Status Quo

Thinking back on this year in healthcare innovations, we have seen significant changes in prior authorization. The prior authorization process is changing from the inside out with progress in machine learning and artificial intelligence. Consider innovations like channel transformation, advancements in interoperability, and nudging (administrative and clinical nudges). 

Topping the list of transformative innovations this year: Sophisticated health plans have started adopting green lighting. Everyone has heard about gold carding, but green lighting exceeds the regulatory minimum in delivering superior results. 

Legislation like gold carding and the recent CMS rule on clinical interoperability and prior authorization has created external pressure to transform prior authorization. The urgent regulatory environment has fueled the appetite for some of the aforementioned innovations. 

Let’s take a deeper look at five disruptors shaking up the prior authorization status quo.

1. New regulatory requirements, both state and federal, are driving forward-thinking health plans to employ intelligent prior authorization solutions.

Health plans are increasing their investments in technology to comply with requirements and standards, such as those outlined in the recent CMS proposed rule on clinical interoperability and prior authorization. Simply automating the prior authorization process is faster than traditional manual processes, but it doesn’t take advantage of the opportunity to drive better patient experiences and outcomes. 

Medicare Advantage plans in particular have a special interest in leveraging clinical intelligence to guide high-value care choices. An intelligent authorization platform efficiently addresses and exceeds the legislative requirements for greater prior authorization automation, transparency, and authorization times by utilizing evidence-based clinical criteria that are clearly defined and referenceable for physicians.

2. The transformation of intake channels from fax and other manual, disjointed sources promises to reduce the administrative burden of prior authorization.

According to a 2020 American Medical Association (AMA) report, 90 percent of physicians state that prior authorization has had a negative impact on patients, and 30 percent report that the practice has “led to a serious adverse event for a patient in their care.” 

A shocking percentage of prior authorization requests are still submitted via fax, with healthcare administration lagging behind other leading industries in modernization. New technology uses machine learning to digitize authorization requests. Decisions incorporate longitudinal patient information and offer providers real-time feedback on their requests, resulting in faster access to care for patients, four days faster on average.

3. Clinical interoperability from native EMR prior authorization intake is growing, which will shorten TATs, unify provider experience, and increase transparency.

Reducing administrative burden continues to be a significant focus going into 2023. Health plans can allow providers to keep their primary focus on delivering effective care by enhancing provider efficiency and experience. 

When providers can submit prior authorizations in the channel they are accessing at the time of care, it enhances and unifies the provider experience. EMR integration provides the unique opportunity to seamlessly include relevant longitudinal patient data from the EMR directly into the request. The addition of clinical intelligence capabilities means nudges can be deployed to suggest site-of-service programs or route patients to appropriate ecosystem partners. 

Of course, improved clinical interoperability increases cost savings, but this framework is especially adept at addressing social determinants of health.

4. Green lighting, a more targeted alternative to gold carding, speeds or eliminates prior authorization for providers who meet specific quality standards.

Gold carding, under a new Texas law, exempts physicians from certain prior authorization requirements when they have at least a 90% prior authorization approval rate over a period of six months. The green lighting approach considers a provider’s longitudinal impact on the patient’s care journey. An end-to-end process provides a more comprehensive assessment of the provider’s quality and value of care than traditional gold carding, which can fall prey to gamification. 

Real-time analytics is the brains behind green lighting. Health plans can incentivize high-performing providers through fast approval with minimal data submission. On the other end of the spectrum, surfacing low-performance providers creates an opportunity to work with them to reinforce best practices.

5. Administrative and clinical nudges are emerging as an AI-driven innovation to further improve provider experience and drive better, faster care.

Introducing artificial intelligence-powered “nudges” into the authorization workflow will improve the provider experience and drive medical expense savings. Administrative nudges, performed during decisioning, increase authorization completeness and accuracy, which in turn increases the likelihood of immediate decisioning. Clinical nudges guide users toward optimal sites of care and alternative services based on the patient’s risk profile. These suggestions go beyond the transaction for which the provider is seeking an authorization; the system intelligently suggests other services, considering the optimal path for the entire care journey.

The placement within the workflow and on the screen are designed deliberately and rigorously tested to optimize provider experience, thereby improving the quality and timeliness of care for patients.

The clinical strategy and innovation team here at Cohere Health is optimistic about the future of prior authorization. Here’s what we’re looking forward to in 2023:

• Faster, better patient outcomes by suggesting optimal care choices based on patient-specific data, population data, and evidence-based criteria 
• Less abrasive provider experience by generating optimal patient-specific care paths oriented to the entire care episode/journey pathway
• More efficient, less costly health plan operations by aligning prior authorization and utilization management with value-based care programs