ONC looks for comments on how to improve prior authorization
The agency is requesting input from the industry for how to use standards and how to implement these in workflows to facilitate the process.
The Office of the National Coordinator for Health Information Technology is taking aim at one of the prime pain points for clinicians, providers, payers and patients – the prior authorization process.
This process is widely used to ensure that treatments for patients are first approved by organizations that cover the costs. While meant to ensure that treatments are effective and costs are controlled, the prior authorization process now is viewed as an administrative logjam that interrupts care and remains highly manual.
Finding standards and using them, which would enable organizations to use data exchange to automate at least some of the prior authorization process, would help improve patient safety, ensure continuity of care, reduce administrative burden and help relieve clinician burden. For example, a May 2021 poll by the Medical Group Management Association (MGMA) indicated that 81 percent of respondents stated that prior authorizations had increased during the pandemic, while only 2 percent said they thought requirements had actually decreased. Nearly four out of every five providers are estimated to use a manual prior authorization process.
ONC last week announced that it is seeking public comment on electronic prior authorization standards, implementation specifications and certification criteria that could be adopted within the ONC Health IT Certification Program.
“Responses to this (Request for Information) may be used to inform potential future rulemaking to better enable providers to interact with healthcare plans and other payers for the automated, electronic completion of prior authorization tasks,” the ONC announced. “Ultimately, such electronic processes will serve to ease the burden of prior authorization tasks on patients, providers and payers.”
While prior authorization aims to control costs and ensure payment accuracy by pre-approving medical necessity and checking to make sure proposed care meets accepted standards, the back-and-forth communication between insurers and providers has been a challenge to automate, and typically requires a separate workflow that interrupts the flow of patient care.
ANSI X12 codes have been available for years to support the prior authorization and referrals process, but still require manual intervention, particularly to handle attachments of documentation to meet payer requirements. Additionally, because authorization requirements differ from payer to payer, providers must know and tailor requests for authorizations.
Some entities have been pushing to automate the process through standards, and the ONC RFI will give a change to provide input. It’s clear that much work will lie ahead.
HL7’s Da Vinci Project has been working to automate the prior authorization process through a mix of three code sets that employ the Fast Healthcare Interoperability Resource (FHIR) standard. The accelerator group’s members are working to combine the following use cases:
Coverage Requirements Discovery (CRD), the implementation guide of which would automate the process that enables payers of communicating coverage requirements to providers. This use case would use CDS Hooks to query payers to determine if documentation is required for services.
Documentation Template and Rules (DTR), which would spell out how to submit documentation to payers.
Prior Authorization Support (PAS), which would enable direct submission of prior authorization requests from EHR systems to payers, and then that such submissions are sent only when needed and containing all needed information.
Da Vinci members are trying the implementation guides in actual production environments and continuing work to ballot the standards. However, the widespread use of automation via FHIR-based application programming interfaces still will need to be tested at scale.
This fall, Da Vinci members saw a presentation involving two vendors, Change Healthcare and ZeOmega, which discussed early efforts to use market-facing payer and provider APIs and FHIR standards to achieve burden reduction in prior authorization.
Other responses to ONC’s request could come from large industry groups that have mounted prior authorization initiatives. For example, AHIP, an organization representing health insurers, has been building what it calls its Fast PATH Initiative, which it started in 2018 by bringing together stakeholders from providers and insurers. Fast PATH has sought to “increase the adoption of electronic prior authorization.” Which it sees as one of the major opportunities to improve the process.
The American Medical Association also has targeted prior authorization for process improvement. It’s convened a workgroup consisting of 17 state and specialty medical societies, national provider associations and patient representatives that developed best practices for prior authorization and other utilization management requirements.
It notes that many of the reforms suggested in a consensus statement the workgroup formulated “have not been widely implemented by health plans.” The AMA maintains a resource page on prior authorization issues, located here.