Maximize Your ROI on Electronic Prior Authorization

A smart API broker and data integration engine. Plans must query multiple systems to determine whether prior authorization is required, from member eligibility to policy coverage to provider status. Likewise, most plans rely on a mix of proprietary medical policies, licensed rules, and delegated vendors to adjudicate required submissions. So, an API broker capable of automatically routing specific requests to the right back-office system is essential. Additionally, many of these legacy systems do not “speak” FHIR, or a uniform standard of FHIR. So, a data integration engine is also needed to enable the bi-directional flow of normalized data that all systems can read and process.

Prioritize the 80/20s to pull forward your plan’s ROI. Translating all medical policies relevant to prior authorization into machine-readable language will be an expansive, ongoing undertaking for most plans. Fortunately, prior authorization requests tend to spike in specific areas. Plans working with InterSystems uniformly report that a limited number of procedures account for an out-sized share of requests. Your plan should focus first on identifying this subset and translating corresponding medical policies into machine-readable language. This approach will maximize the number of members and providers experiencing faster prior authorization decisions while minimizing the volume triggering costly, manual administration.

Make sure your ePA solution is reliable and saves provider time before “go live.” CMS-0057 effectively requires that providers try the new FHIR-based process it mandates plan support, but not use it consistently. Consequently, a favorable first experience is critical to driving broader utilization. When change is optional, negative first impressions often hamstring the introduction of new processes, no matter how promising the new approach nor subsequent upgrades. Efforts to educate providers about how best to leverage new ePA capabilities are a worthy investment. However, the most important factor for catalyzing widespread adoption is that your technology works as advertised the first time providers use it for prior authorization.

In short, yes, provided your ePA architecture and rollout account for three key factors. First, transaction volumes—your system must be able to process far more queries with no erosion in reliability and fidelity. Second, administrative silos—your API broker must be able to route queries to what may seem like duplicative systems serving different lines of business. Third, different 80/20s— there maybe variation in which subset of medical policies you should front-load for translation into machine-readable language to maximize the number of members and providers benefiting from faster prior authorization decisions in the nearer term.

Absolutely. InterSystems is building AI applications to both streamline complex processes and diagnose systemic choke points. But there is a common prerequisite to the utility of all such applications in healthcare: data quality. AI will require vast amounts of timely, accurate data to meaningfully improve prior authorization and, more generally, advance value-based care. To harness the promise of AI, plan leaders must pair AI pilots with investment in growing harmonized, normalized data sets that integrate disparate clinical, administrative, and SDOH data streams and are readily available for multiple use cases.