High-Tech Solutions for Prior Authorization Problems

Nate Gosse, PhD
Published: Wednesday, Jun 07, 2017
Nate Gosse, PhD

Nate Gosse, PhD

Several provider challenges and opportunities were highlighted during the 2017 State Oncology Society Forum, hosted by the National Comprehensive Cancer Network (NCCN) at its annual conference, held in March in Orlando. Presenters and attendees discussed how the application of technology can drive significant near- and long-term benefits by easing prior authorizations (PAs), increasing information exchange, and balancing the roles between technology and human interaction in patient care.

Addressing the Challenges of Prior Authorization

PA requirements continue to increase as higher cost treatments, including oral and injectable therapies, are used in the treatment of cancer. Although payers initially developed the process to verify that a treatment is appropriate for a specific patient’s condition before the start of therapy, recent trends have led many providers to conclude that PAs are primarily a subterfuge intended to reduce costs and risk for payers; they have little regard for provider challenges or the burdens they place on patients.

Many oncology practices indicate that the PA workflow and process continue to be frustrating, time consuming, and expensive. Billing staff commonly initiate the process of gathering information and communicating with payers or their intermediaries to confirm that therapies or imaging tests are evidence based. However, the increasingly finegrained inquiries of payers often require the involvement of expert clinical staff and physicians. The labor time and disruptions in workflow can increase costs and delay patient care. Commentary from the podium and audience at recent oncology meetings has suggested these delays can stretch to 2 weeks or longer.

The slowdowns are visibly frustrating for patients and their families who already feel anxious about their diagnoses and impending treatments and are not commonly aware of the behind-the-scenes hurdles their care teams face. These feelings compound with each additional day, as patients wait for scheduling and more information and look to their providers for guidance and affirmation that they’re clear to begin or continue the battle against their disease.

PA difficulties are only growing worse as payers view this process as an acceptable means of data collection and verification; however, this is where technology can improve the situation for patients and their providers. A best practice to help streamline the PA process involves use of decision-support technology that integrates with an electronic health record (EHR) system to give physicians direct visibility of evidence-based treatment options at the point of care. With further clarity on which treatments are recognized by clinical guidelines and pathways, a physician can make recommendations that are likely to meet thresholds for compliance for PA and payment. Access to this information at the point-of-care leads to a quicker turnaround time for PAs and means patient delays and anxiety are minimized.

These tools also can ensure all necessary clinical data have been considered and captured, streamlining the workflow of the business office and clinical staff by easing the burden of paperwork, number of clicks, and other time spent on PAs. Integrating a decision-support system with Web-based PA portals can help to initiate cases and eliminate manual re-entry of patient details, further reducing delays and staff burden.

When choosing technology, a practice should find a solution that offers point-of-care access to the library of NCCN Guidelines—the most widely recognized clinical treatment recommendations in oncology. From their technology, providers should also expect narrower clinical pathways, visibility into treatment cost, and the ability to highlight payer-specific preferences (or coverage) for patients. The ability to directly transmit required information for PA submissions and to provide real-time reporting and physician feedback will ensure that the challenges of PA can be minimized. This will enable physicians to focus on practicing medicine, not negotiating with payers.

Sharing Information Between Systems

In the consumer world, we quickly become irritated if we are repeatedly asked to provide the same information to complete a transaction. Yet in healthcare, we are only now moving to an era in which the same information or data can be repurposed to complete multiple tasks.

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