Health plans are hyper-focused on compliance right now as they unpack new interoperability and transparency standards for prior authorization coming down from the Centers for Medicare and Medicaid Services (CMS). Many health plans are looking to intelligent prior authorization to catch up with regulations, but more forward-looking plans are already thinking about what’s coming next. Intelligent prior authorization gives plans a competitive advantage.

Start making the most of your data and use it to drive automated decisioning and improve care outcomes for patients. For more on how to satisfy requirements for information exchange between stakeholders, check out Regulatory 360: Two provisions to watch in the CMS prior authorization rule.

To help illustrate how intelligent prior authorization capabilities will enhance the results of compliance with new interoperability and transparency regulations, consider the path of information during a service request transaction below:

Intelligent prior authorization speeds up the flow of information through the three stages of a transaction

1. Coverage requirements discovery

Information being exchanged: 

• Prior authorization lists (PALs): Which services require prior authorization
• Clinical criteria/guidelines: What clinical evidence is needed to determine medical necessity

Key players: Health plans share this information with providers

Historically, this process was largely manual. Differences between health plan coverage and policies make it difficult for providers to definitively know the answers to either of these questions. As a result, they might send all of the clinical information they have for a patient, which can clog the workflows of clinical reviewers unnecessarily. This added burden lengthens the turnaround time for the service request and can delay care.

Digitizing intake across multiple channels helps improve interoperability at this stage. Regardless of whether requests are submitted via manual methods (phone or fax) or digital ones (portal or EHR integration), intelligent prior authorization acts as a digital front door, collating clinical information across platforms and digitizing it for automated decisioning. Digital interfaces like portals and EHR integration increase the transparency between health plans and their provider partners, making it instantly clear to providers which services require authorizations and what clinical evidence is needed.

2. Clinical documentation and decisioning rules

Information being exchanged:

• Clinical documentation 
• Clinical criteria/guidelines

Key players: Health plans can utilize intelligent prior authorization to speed clinical documentation processing in accordance with health plan policy. 

Legacy prior authorization decisioning is a highly manual process. Clinical reviewers comb through pages of clinical documentation in order to satisfy the health plan’s criteria for an approval, citing evidence for their answers. To help improve the process, some health plans request providers to fill out clinical assessment questionnaires, but the process remains burdensome and time-consuming for both providers and health plans.

Three ways intelligent prior authorization improves the exchange of information throughout the process include:

1. Digital intake channels and the use of OCR to convert physical forms into a machine-readable format enables automated clinical decisioning and faster manual reviews.
2. Automated decisioning rules engine approves 87% of case volume according to plan criteria and AI-leveraged administrative data
3. Clinical pre-processing applies clinical intelligence to provider-submitted evidence to package the most relevant information for reviewers, accelerating manual review

3. Prior authorization support

Information being exchanged:

• (Automated) approval notifications
• Pended case notifications
• Denial notifications

Key players: Health plans can use intelligent prior authorization solutions to share these notifications with providers and patients

Since the majority of prior authorization is conducted via analog channels like fax, decision notifications were often delivered in the same way. This process is especially problematic for denied cases, which may require the requesting provider to resubmit with missing information. Extended time required to conduct a peer-to-peer review, outreach for missing information, or any additional communication all contribute to an extended turnaround time and can delay patient care.

By allowing requesting providers to access information about decisions at any time, health plans can create more transparency. In-network providers benefit from visibility into patient claims and encounter data (excluding cost information), data elements identified in the United States Core Data for Interoperability (USCDI) version 1, and prior authorization requests and decisions. This information can help patients better understand their health plan’s prior authorization process and its impact on their care.

While it’s hard to prioritize an implementation of this scale because standards are constantly changing, there’s an incentive to invest in streamlining your data infrastructure now. For example, though CMS regulations only affect a discrete line of business, intelligent prior authorization solutions can help health plans better manage the PAL differences between regional and lines of business.

While evaluating technology to help with compliance, consider how intelligent prior authorization can take your plan beyond automating and streamlining manual prior authorization processes and bring longitudinal context to individual prior authorization transactions. Health plans can leverage intelligent prior authorization solutions to help improve their interoperability and data infrastructure. As a company on the cutting edge of advanced technology application in the prior authorization space, Cohere has been encouraging the adoption of Da Vinci standards with its health plan partners since its founding.

Download our white paper to learn how intelligent prior authorization can help with the four provisions of the CMS rule.