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Prior Authorization – A Burning Problem in Need of a Solution

[fa icon="calendar'] Apr 20, 2021 12:52:49 PM / by Lynda Rowe posted in FHIR, HL7 community, interoperability, Da Vinci, value based care, prior authorization, FHIR Accelerator, FHIR Implementation Guides

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Those of us who have been in healthcare a long time know that prior authorization can been a challenge for both payers, providers, and patients. One might think it’s time to remove prior authorization altogether, but until we have consistent clinical practice across the entire US healthcare system, it’s very hard to justify.

The current processes create a huge burden for providers and payers, and cause delays sometimes critical in patient care.

Why is prior authorization such a thorny problem[i]?

  • Prior authorization issues contribute to 92% of care delays
  • Nearly all of provider care delays are associated with inefficiencies and administrative issues with current prior authorization
  • Providers take 6 hours on average to complete these requests, which is the equivalent of two business days. Thirty-four percent of providers have staff dedicated exclusively to completing prior authorizations.
  • The prior authorization process costs $23 to $31 billion per year in the US, according to a 2009 study published in Health Affairs.
  • The health plan cost per manual prior authorization is $3.68, compared to $0.04 per electronic prior authorization, according to a 2017 Chilmark Research report.
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HL7 Da Vinci Project Recaps Standards Progress, Looks to Document Value of Implementation Guides

[fa icon="calendar'] Mar 10, 2021 9:14:05 AM / by Fred Bazzoli posted in FHIR, HL7 community, interoperability, Payers, Da Vinci, value based care, prior authorization, Gaps in Care, FHIR Accelerator, patient cost transparency, risk-based coding

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Project Achieves a Tipping Point as Adoption Begins in Earnest to Meet Upcoming and Proposed Federal Regulation and Solve Interoperability Challenges

The Da Vinci Project made significant progress in 2020 in advancing the maturity of implementation guides, and now looks to increasingly demonstrate the value of its implementation guides (IGs) across production implementations this year.

Members of the HL7 FHIR® Accelerator group helped push forward work on several implementation guides that were published in 2020, but further refinement lies ahead, said project managers who presented a progress report on the Da Vinci Project at its January Community Roundtable.

In addition to the update on progress with publishing new standards, the presentation offered members a tour of the Da Vinci Project’s enhanced Confluence website, as well as an invitation for more organizations to consider membership to help ensure implementation guides meet the needs of the entire healthcare community.

This year, there will be a growing need to use the HL7 Fast Healthcare Interoperability Resources (FHIR®) standard, as application programming interfaces (APIs) emerge to meet federal information exchange requirements and business needs of value-based care.

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Reducing Industry Burden Focus of February’s HL7 Da Vinci Project Community Roundtable

[fa icon="calendar'] Feb 15, 2021 4:37:09 PM / by Fred Bazzoli posted in FHIR, HL7 community, interoperability, Payers, implementation, Da Vinci, value based care, implementation guide, prior authorization, FHIR Accelerator

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Join the Webinar Highlighting MCG Health’s Prior Authorization Journey and Da Vinci’s Two New Use Cases for 2021 on Wednesday, February 24 from 4:00 - 5:30 pm ET.

Healthcare organizations increasing their exposure to value-based care find many tasks complicating the transition, and reducing the burden of those changes is key to thriving under new reimbursement schemes.

New payment approaches incentivize both payers and providers to become more efficient, and that means reducing the number of manual interventions in exchanging data. In addition, value-based care is uncovering new reasons to make information more easily available, to bring new efficiencies to the system.

Examples of these capabilities will be featured in the HL7 Da Vinci Project’s Community Roundtable on February 24. The title for the event is "What it Takes: Learn about MCG Health’s Journey to Help Reduce Prior Auth Burdens and Discover New Da Vinci Use Cases."

The upcoming roundtable will offer an inside understanding of the 18-month effort at MCG Health to advance the use of the HL7 Fast Healthcare Interoperability Resource (FHIR®) standard in solutions that support burden reduction in facilitating the prior authorization process.

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CMS New Rules to Address Prior Authorization for Patient and Provider Interests

[fa icon="calendar'] Feb 8, 2021 12:23:17 PM / by Shobhit Saran posted in FHIR, interoperability, health IT, Payers, CMS, Da Vinci, prior authorization, ONC, payer data exchange, Patient Access API

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The Centers for Medicare & Medicaid Services (CMS) released the much-awaited Interoperability & Patient Access Rule in March 2020. The objective is to reinforce this rule by further improving health information exchange and obtaining member health records at a single location to reduce burden on payers, providers and members.

The enforcement date for this rule is January 1, 2023, and will be applicable to Medicaid programs, the Children’s Health Insurance Programs (CHIP) and Qualified Health Plan (QHP) issuers on the individual market Federally Facilitated Exchanges (FFEs). However, it will not be applicable to Medicare Advantage (MA) plans.

The CMS proposed rule will include policies to enhance the current Application Programming Interfaces (APIs) from its interoperability rule such as patient access API and payer to payer API. There are a few new APIs and requirements proposed to improve the overall prior authorization process.

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HL7 Da Vinci Project Use Cases Aim to Reduce Documentation Burden in VBC

[fa icon="calendar'] Jul 16, 2020 4:09:54 PM / by Fred Bazzoli posted in FHIR, HL7 community, interoperability, SMART on FHIR, health IT, implementation, Da Vinci, value based care, implementation guide, prior authorization, coverage requirements discovery, documentation templates and payer rules

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Report from Virtual FHIR DevDays 2020 on HL7 Da Vinci Project Use Cases

Developers are fine-tuning ways to use the HL7 Fast Healthcare Interoperability Resource (FHIR) standard to reduce communication challenges and decision impediments between providers and payers.

Working on use cases involving coverage and burden reduction, the HL7 Da Vinci Project is refining early versions of standards and developing implementation guides for value based care (VBC). Speaking to more than 150 attendees during the virtual HL7 FHIR DevDays event, Dr. Viet Nguyen, Da Vinci Project Technical Director, noted that the coverage and burden reduction use cases are intended to address workflows around provider-payer interactions. FHIR implementation guides are then created based on a set of use cases. 

Coverage Requirements Discovery

One use case, Coverage Requirements Discovery, gives providers real-time access to payer approval requirements, documentation and rules at point of service to reduce provider burden and support treatment planning. In its essence, this would answer a provider’s question about whether a procedure or treatment needs a prior authorization from a payer. The aim is to use CDS Hooks to supply an answer to a clinician posing the request within his or her workflow. Work is continuing on developing an implementation guide for this use case.

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HL7 Da Vinci Project Use Cases Show Progress in Exchanging Information, Achieving Efficiencies

[fa icon="calendar'] Apr 22, 2020 12:58:18 PM / by Fred Bazzoli posted in FHIR, HL7 community, interoperability, Payers, Da Vinci, value based care, implementation guide, prior authorization

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All Are Welcome to Attend Da Vinci Community Roundtable

[fa icon="calendar'] Mar 20, 2020 11:16:48 AM / by Jocelyn Keegan posted in FHIR, HL7 community, interoperability, Payers, Da Vinci, value based care, implementation guide, prior authorization

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