Enhancing Provider Experience Through Electronic Prior Authorization

Krithika Srivats, MSOTR, SVP, Clinical Practice and Products, Sagility; Nikki Henck, Senior Director, Utilization Management, Sagility

Each year the American Medical Association (AMA) surveys its membership to ascertain their feedback concerning prior authorizations (PAs) and the impact of this service on their practice. Reliably, AMA members say that PAs are disruptive to their practice, resulting in higher cost to the entire health care system as well as impact to patient care. Yet the insurance industry is at a crossroad as to where technology can provide immediacy to minimize the abrasion many practices endure daily. The key to this is how.

The Confluence: It Takes an Industry to Solve the Prior Authorization Burden

Health plans are experiencing the confluence of regulatory requirements on the federal and state levels. A number of states have enacted requirements regarding the provision of electronic prior authorization (ePA) submission process (typically via a portal). On the federal level, the Center for Medicare and Medicaid Services (CMS)-oo-57F rule mandates that payers improve the prior authorization process by shortening turnaround times, making determination communication more transparent, and enabling interoperability to support electronic prior authorization at the point of care.

Make Portals Easy to Use and They Will Come Back

The deployment of utilization management (UM) portals is increasing due to state and federal mandates. In the world of technology, the old adage “build it and they will come” is a recipe for disaster when it comes to ePA. For what it’s worth, a poor portal experience will not improve provider collaboration; however, it will cause undue frustration for practices.

Most technology users will not use an application if they experience technical glitches, long response times and poor navigation. Typically, after a number of poor sessions, a user is unlikely to use the application. Yet it is critical and optimal for payers to receive prior authorization requests electronically. Additionally, most providers have limited time to complete a prior authorization request, and most submissions are submitted by an office manager or nurse.

For these reasons, payer portals must provide a friendly, flexible, and immediate experience for the end-user. Payers need to consider the following features that will provide a better user experience and improve adoption:

• A standard submission form with ability to attach documents • Minimizing tasks and keystrokes to reduce the time a practice has to complete their submission, which can be achieved through auto-prefilling information and validating data
• Enabling real-time administrative validation such as eligibility and par provider verification, prior authorization requirement (whether or not a service requires prior authorization)
• Prompting the user for specific information so they know what information is being requested
• Centralized dashboard that enables users access to all their activities and offers tools for self-service (such as status checks, which can reduce calls to the contact center)
• Push notifications and alerts as status changes or when information is needed
• Orchestrated user experience that prompts users to take the next action, these can include bots and avatars to guide the prompt the user to close a loop
• Intuitive look and feel that enables users to navigate through their prior authorization submission

Key Strategies to Promote Portal Adoption

The 2023 CAQH Index found that plans’ adoption of partially electronic prior authorization (web, portals, IVR) is 32%, while fully manual processing stands at 37%. In a digital era, this is just sad. 

To drive adoption, payers automate the prior authorization submission flow to provide immediacy and transparency of decisions. This will improve provider collaboration by helping provider practices to understand coverage and clinical criteria for specific conditions. Increasing provider adoption of ePA and improving provider collaboration will require payer portals to enable the following:

• When launching a portal, plans need to prioritize provider education, which is critical to provider adoption. Plans must make it a point to communicate the changes, provide online access to self-service webinars design to help onboard the practice, Help Desk support for access issues and targeted outreach to practices that submit a high volume of requests.
• More than 80% of automated approvals for requests can be adjudicated based on rules. When implemented properly, providers can obtain a favorable authorization at least four out of five submission experiences.
• Real-time authorizations for select or specialty services require a medical necessity assessment (typically via a digital clinical care pathway) at the point-of-care. This will result in less abandonment in treatment and or fragmentation in care.
• Transparent communication such as real-time acknowledgement with authorization code, letters, and rationale not only provide providers with the information they need but also educate them on the plan’s policy/criteria for approval.
• Real-time bi-directional data exchange such as requests for additional information by the payer can be satisfied by enabling the providers’ ability to be prompted to provide additional information and allow them to upload documents and images.

Many payers have layered their technology UM stack over the years to meet compliance. What is crucial to the success of provider adoption of ePA is that a plan’s tech environment is fully integrated to support the real-time exchange of data and updates between systems.

UM portals can act as a turnkey technology for payers to minimize the abrasion providers often experience with respect to prior authorizations. By improving provider user experience, plans will improve adoption of portals and reduce volume to its contact centers and clinical reviews.

About the Authors

Krithika Srivats, MSOTR, is Senior Vice President, Clinical Practice and Products at Sagility, a technology enabled, pure-play healthcare-focused solutions and services provider. Krithika has 25+ years of diverse experience in patient care, strategic disease management in the field of Alzheimer's and related dementias and, as an occupational therapist, has a passion for helping elders live safely at home.

Nikki Henck is Senior Director, Utilization Management at Sagility where she oversees strategy and delivery for Sagility Utilization Management and Specialty Solutions. Nikki has over 17 years of healthcare experience in the areas of strategy, solutions, operations, technology, and implementation.