Green Lighting Solutions to Address Barriers in Health Care Prior Authorizations

Please introduce yourself by stating your name, title, organization, and professional experience.

Dr Brian Covino: I am Dr Brian Covino, Chief Medical Officer at Cohere Health, where I oversee more than 50 physicians. My team of doctors ensures the company's intelligent prior authorization platform is grounded in evidence-based clinical knowledge and expertise. Before joining Cohere as one of the first employees, as a consultant (2018), then full-time (2020), I spent over 25 years as a practicing orthopedic surgeon.

Throughout my career, I specialized in joint replacement surgery and served as a partner at Knoxville Orthopaedic Clinic/OrthoTennessee.

My academic background includes a bachelor's degree from Harvard University and a Master's and MD from Georgetown University School of Medicine. I received my surgical training at the University of Virginia Graduate School of Medical Education and completed a fellowship in Joint Reconstruction Surgery at The Cleveland Clinic Foundation.

Electronic prior authorization adoption faces certain barriers, such as providers not using EHRs enabled for electronic prior authorizations and the cost of EHR upgrades. Can you discuss how prevalent barriers for prior authorization are and what strategies health plans could employ to overcome them and promote wider adoption of electronic prior authorization?

Dr Brian Covino: Recent industry-wide survey results showed that 88% of health plans want to streamline prior authorization by using electronic prior authorization for medical services. However, barriers to electronic prior authorization adoption within the health care industry are impacting the seamless integration of this technology.

Barriers include limited electronic health record (EHR) adoption by many providers (71%) due to concerns about changes in workflow, increased administrative burden, and potential disruptions to patient care. Additionally, the prevalent use of nonelectronic submission methods, such as phone and fax, persists due to resistance stemming from concerns about workflow changes and the poor quality of electronic platforms for submission. There are also interoperability issues for those lacking the necessary technology infrastructure, impeding the smooth exchange of data required for electronic prior authorizations.

While upgrading EHR systems to support electronic prior authorizations can be costly for small providers, health plans can encourage wider adoption through financial incentives, standardized processes, education, pilot programs, and supportive regulations. This will streamline the authorization workflow, benefit providers, and improve patient care.

Health plans have been adopting various methods to streamline prior authorization processes, with a significant focus on 'gold carding' for medical services. Can you elaborate on what 'gold carding' entails and how it has evolved from 2019 to 2022 according to the survey results?

Dr Brian Covino: Gold carding aims to simplify and expedite the approval process for specific medical procedures as' gold card' providers are not required to submit approval requests, reducing administrative burdens and improving access to care. Health plans adopt this strategy to attempt to make the prior authorization process more efficient while maintaining a focus on quality and compliance. Health plans may designate certain providers or services as eligible for gold carding based on the provider's adherence to guidelines and demonstrated efficiency.

This isn't a new concept, but it has evolved over the past few years, and a recent survey illustrated the growth of gold carding adoption from 2019 to 2022. For example, the use of gold carding for prescription medications rose from 9% in 2019 to 21% in 2022 and from 32% in 2019 for medical services to 58% in 2022.

West Virginia led the way in 2021 with a gold card program exempting providers with 100% prior authorization success for a service from future requests, followed by Texas in 2023 with a more lenient 90% threshold. Michigan joined this trend for commercial insurance in 2023, while Louisiana also passed legislation. With at least eight more states, including Indiana, Kentucky, and New York, considering similar bills, the gold card trend aims to address the administrative burden of the prior authorization process.

While 'gold carding' has seen increased popularity, survey results reveal varying perspectives among health plans regarding its effectiveness. Could you provide insights into the key findings related to how health plans perceive the impact of gold carding on provider burdens, satisfaction, patient safety, and the challenges faced in implementing this approach, including those leading to the discontinuation of gold carding programs?

Dr Brian Covino: Gold carding has elicited varied reactions due to worries about increased health plan documentation, potential quality and cost management declines, and implementation difficulties. For example, gold carding involves manual analysis and categorizing physicians into broad programs using data as old as 6 months. Moreover, being labeled as a gold card provider does not ensure payment, as it skips the prior authorization process, requiring claims to have corresponding permission for validation.

Difficulties in assessing quality and compliance until after a claim is submitted and the service has been delivered further complicate matters. This adds another layer of uncertainty and potential risk.

Another significant drawback of gold carding is the potential for heightened utilization, especially among providers who had previously met rigorous approval thresholds when proper oversight is absent. These combined gaps in productive usability are prompting many health plans to discontinue gold carding programs and find alternatives.

The top reasons health plans and providers are discontinuing their use of 'gold carding' are:

• Administratively difficult to implement (75%)
• Reduced quality and patient safety (50%)
• High costs without improved quality (25%)

With 'gold carding' perspective shifts in mind, can you elaborate on the key reasons behind this shift and how green lighting leverages real-time data and analytics to address the concerns raised by some about the extra paperwork and potential impact on the quality of care associated with gold carding?

Dr Brian Covino: Green lighting is a sustainable alternative to traditional prior authorization methods, which replace manual gold carding with a real-time, code-level data approach for faster approval. Advanced analytics help providers harness the power of vast datasets to gain insights into patient populations, disease trends, and risk factors through a more expedited, automated approach.

Green lighting offers providers several valuable capabilities, including addressing patient safety concerns and providing an opportunity to suggest alternatives, such as more appropriate sites of service for procedures.

Additionally, green lighting enables the continuous monitoring of utilization in real time. This means observing and acting on a physician's actions immediately after obtaining a prior authorization status, without the typical delay of three to six months, allowing for the ongoing assessment of medical necessity.

How do these aspects contribute to making green lighting an essential shift in the health care industry, and what specific benefits does it offer in terms of promoting collaboration between payers and providers for equitable care access and quality improvement?

Dr Brian Covino: Green lighting helps move the digital needle in health care by shifting from the historical analysis of gold carding to real-time data-driven decisions. This empowers providers to optimize patient care, resource allocation, and operational efficiency, placing high-quality care at the forefront of the prior authorization process rather than relying on past performance. In essence, green lighting allows health care to proactively adapt to the needs of the present, paving the way for a more patient-centric future.

Benefits of green lighting include enhanced patient outcomes, streamlined documentation, and a more comprehensive physician evaluation. This method reduces errors and ensures precise determinations for quicker patient access to care. This data-driven method aligns with health care technological advancements, prioritizing quality, accessibility, and cost-effectiveness.

What is one thing you'd like the audience to walk away with from this interview?

Dr Brian Covino: The main point I'd like to emphasize is that the digital revolution is now, and the longer providers and health plans delay the move to electronic prior authorization, the greater the disservice they're doing to themselves, their colleagues, and their patients.

On the heels of last month's Interoperability and Prior Authorization rule by the Centers for Medicare & Medicaid Services, health plans will be required to invest in advanced technology to ensure compliance with federal prior authorization requirements. Green lighting is a path forward that automates workflows, reduces red tape, and complies with regulatory changes to tighten turnaround times (TAT), all while keeping pace with cutting-edge technology and evolving patient needs.

As health care organizations embrace its potential, green lighting paves the way for a data-driven future where quality, accessibility, and affordability are paramount.