The Future of Prior Authorization

In 2010, the amount of medical knowledge doubled every 3.5 years. In 2020, it doubled every 73 days.

This is why prior authorization is so important. It helps ensure patients receive the most optimal treatment based on their precise diagnosis, prognosis and the latest clinical evidence. By keeping providers up-to-date on critical nuances in treatment procedures and clinical guidelines, prior authorization protects patients from receiving unnecessary—and potentially harmful—tests and treatments. It also connects patients with the right treatment as quickly as possible to achieve better health outcomes sooner, whether they be full recovery or optimal management of chronic conditions. Together, these efforts help reduce health care costs in the long run for both patients and plan sponsors.

Making prior authorization more efficient and effective

Right now, prior authorization can increase administrative burden for providers. In some cases, there can be delays in treatment—especially if the health plan or the doctor don’t have the necessary information to make the best clinical decision. However, there are ways to improve the prior authorization process to address these issues.

• Increase automation to reduce administrative burden. Electronic prior authorization processes can save time for both providers and plan sponsors. Various systems and tools seamlessly integrate with provider electronic health records to automatically collect patient data needed for the authorization process, reducing the need to follow up with providers for additional information. These applications can go a step further by using sophisticated algorithms—and even artificial intelligence—to speed up approvals for prior authorization requests that meet clinical guidelines. That is how eviCore’s IntelliPath^® solutions drive quick approvals for certain types of medical services, such as radiology in cancer care. 
• Engage with providers earlier to help with clinical decision-making. Typically, prior authorization takes place after a clinician decides on the recommended tests and/or course of treatment. By incorporating the process earlier in the workstream, plans can partner with clinicians at the beginning of a patient’s journey. This provides doctors access to the most up-to-date clinical evidence from the start—giving them a powerful resource to help identify the most clinically appropriate treatment for a particular patient.
• Empower patients in the process. Right now, patients are not that involved in—or even aware of—the prior authorization process. Most don’t even know about it unless a certain test or treatment has been denied coverage. However, it is important for patients to have full transparency of the entire process. Not only would this help patients stay informed of authorization decisions, it would also allow for education opportunities about their particular condition and appropriate treatment options. Bringing patients into the prior authorization process can also help close information gaps, as patients would have an opportunity to provide any missing information from the provider’s request that would otherwise delay authorization approvals.

Partnerships are vital to advance prior authorization

Plan sponsors can take steps to improve the prior authorization process by working with providers to enhance productivity, and with expert organizations and medical systems to advance that connectivity on a broader scale. For example, eviCore partners with several providers to determine the best places to incorporate prior authorization procedures and automations in their practices to address administrative issues and improve workflows. On a larger scale, Evernorth is a premier member of the HL7 CodeX initiative, where we are leading an industry-collaborative pilot to enhance prior authorization for radiation oncology cases (beginning with breast and prostate cancer) by implementing automated processes in the early stages of the radiation oncologists’ workstream. On the patient side, eviCore is currently working with health plan clients to design a special web portal that will enable transparency and collaboration with patients during the prior authorization process.

Ultimately, these advancements in prior authorization will make it even easier for patients to receive the care they need for their specific condition, right away, by enabling a more efficient and collaborative exchange of information that accelerates evidence-based decision making while reducing administrative burden for providers. With more timely connections to the most appropriate care, plan sponsors can expect improved treatment outcomes across their populations, as well as reduced health care costs overall.