What’s it Going to Take to Fix Healthcare’s Chronic Prior Authorization Pain?
In this far-ranging discussion, two experts in health care explore current and potential solutions to the much-hated process of prior authorization in medical care.
Shereese Maynard, MS, MBA, Co-Owner at Nostradata Medical, calls prior authorization “critical yet contentious.” The way it’s done now, in her assessment, it ends up increasing costs “down the line” because patients’ care is denied and their conditions worsen. Plus, the requirements for prior authorization in Medicaid are marginalizing patients.
Colin Banas, MD, MHA, Chief Medical Officer at DrFirst, reports daunting statistics about the physicians’ view of prior authorization. Nine out of 10 believe it has a negative effect on treatment, and a quarter have seen adverse events such as unnecessary hospitalizations.
Both Maynard and Banas believe that the industry could reduce the number of prior authorizations, although doing so would require careful evaluation of the value of prior auth to payers and the impact they have on clinicians and patients. For instance, the insurance giant United Healthcare now defines procedures that don’t need prior authorization. In emergency care, prior authorization isn’t required. “Let’s see some of these prior authorizations go away,” she says.
Maynard and Banas also discussed the role of AI, including the large language models (LLMs) used in the well-known generative AI services. DrFirst recently acquired Myndshift, which uses robotic process automation (RPA) and other AI to compile lists of rules (which are being continuously updated), interpret these rules, automate submissions, and tracking prior authorizations on a dashboard. Banas says that DrFirst automates more than 80% of the prior authorizations they handle.
Maynard and Banas also mention the scandal of issuing blanket denials for large swathes of physician requests without examining them. Although AI was used recently to do this, Maynard said it is “nothing new.”
Other ideas raised in the video include “gold carding” for specialists who have a solid track record of prior authorization approvals and therefore should face less bureaucracy, along with improved interoperability, ways to better track processes and outcomes, and real-time prior authorizations.
Already, Maynard reminds us, the time limit for prior authorization has been legally reduced from 14 days to seven, and just one for urgent requests.
Banas defines the key traits required for reform as consistency, transparency, and automation. Maynard says that technology can now individualize care to a greater degree and determine “what a patient’s real needs are.”
Watch the video for these experts’ insights on the important topic of prior auth.
By Andy Oram, Article Link
Learn more about DrFirst: https://drfirst.com/
Learn more about Myndshyft: https://www.myndshft.com/
Learn more about Nostradata Medical: https://www.nostradatamed.com/
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