Kismet (n.): When you encounter something by chance that seems like it was meant to be, then it could be kismet, your destiny.
An Important Tool: The "Hammer" of Prior Authorization
A provider submits a request for a test on a patient's behalf. The process results in an approval the great majority of the time. It can be frustrating however, in the unusual situation when the request is felt to be inappropriate. The process isn't necessarily over at that point, yet that "hard stop" is what makes the prior authorization process effective. To the provider submitting the request, the process of prior authorization can feel like there's a hammer that can come down at any time, denying their request. That is far from its intended purpose and not why the check and balance process of prior authorization is an important element of the healthcare system. It is frequently the only type of process that results in more appropriate utilization of healthcare services. The prior authorization process attempts to ensure proper utilization of resources saving money along the way.
Many providers believe that they only order appropriate studies, however the data shows that self-management and voluntary adherence to evidence-based criteria is difficult in a world where technology is continuously evolving. Keeping up with the latest evidence-based criteria is difficult.
Many providers would like to play more of a role in utilization management. Oftentimes, self-regulation can work in a hospital setting with peer review committees, but there's no hard stop in that situation either. As Dr. Julius Torelli of eviCore healthcare (eviCore) puts it: "A guideline is a guideline and it's never going to apply 100% of the time." But when a patient's health is at stake, as a physician, you feel that you must do something and everything in your power to help them. When you may not be sure what's going on or what to do, ordering a test seems like the most reasonable thing ".
Transitioning from Black Box to Better Prior Authorization Reviews
Peer-to-peer reviews, or calls between providers and prior authorization physician reviewers, can be frustrating when the person on the other side seems unwilling to listen to the provider's assessment of the patient's situation. eviCore is pleased, says Dr. Torelli, to be strongly interested in feedback from provider offices and practicing physicians with whom we speak. Survey results show terms and phrases like "approachable" and "listens to you". It is important, he says, that even in disagreement about the medical necessity or appropriateness of a given procedure or test, eviCore personnel treat the provider professionally and with respect staying aware that the provider is doing what he feels is best for this particular patient.
Ten to 15 years ago, this industry was very much like a black box, says Dr. Torelli. A provider would send in a request and simply wait for an answer to come back, without insight into why some requests were turned down and what criteria were being used to make decisions. To humanize the process, he says, we felt that we had to put a "face" to eviCore. If we wanted to become more patient-centric, we needed to be more provider-centric. The better the relationships that we could cultivate with the providers we worked with, the more that goodwill and harmony would flow down to the patient.
How did we enhance the process?
We decided that we needed a Provider Engagement team ― local staff that are knowledgeable about eviCore processes and procedures with whom providers would have direct access. From a financial standpoint, this was a big decision. Having a team available to travel to individual offices and provide education on how to efficiently navigate the eviCore system is an expensive process. We decided to look at it as an investment believing that educating the provider and offices would improve efficiency by leading to less requests with inadequate information to make a decision and less inappropriate requests. All this would lead to less case reviews and less peer-to-peer calls and decrease costs.
Dr. Torelli also knew that he also needed to change the presumption of what peer-to-peer calls would be like — adversarial from the beginning. This negative idea about the calls lead to less professional more tense calls, as opposed to more of a partnership that improves the quality and processes of care. In the end, we are both attempting to achieve the same goal – what is best for this individual patient. The truth is, most calls are collegial in nature, with only a few taking a more confrontational nature; however, it is important that all of these calls end on a positive and educational note to Dr. Torelli.
His goal when he joined the eviCore (then MedSolutions) team was to make every peer-to-peer an educational experience. "I may not always be the one doing the educating. I may be the one getting educated, but that's okay," he says.
Our medical directors are all clinically experienced and are therefore able to identify with a wide range of situations that the ordering physicians might be facing. Conversing with someone who you feel can identify with the situation and is willing to listen and hear you is a much more positive experience than dealing with someone who is simply going to try and explain to you why a test choice is wrong. "We make sure we hire physicians who have a lot of clinical experience," he says.
Since joining the team, Dr. Torelli has worked hard to embed a culture of authentic readiness to engage in respectful and collegial dialogue with our provider colleagues.
Call It Kismet
Dr. Torelli's story of how he came to eviCore and what made him want to switch from clinical medicine is informative on the value of the prior authorization process.
As a practicing cardiologist, Dr. Torelli knew about prior authorization, but didn't have any idea about what companies provided this service. He had been working in a solo practice, and then joined a multispecialty group as the only cardiologist. One day, the non-clinical office administrator responsible for prior authorization requests came to him with an ordered test. She told him the test wasn't going to be approved. He asked her why she felt that it wouldn't be approved. She showed him the MedSolutions (now eviCore) criteria used to make decisions in the prior authorization process for nuclear stress tests. After reviewing them, Dr. Torelli agreed it wouldn't be approved, saying "And you know why it won't be approved, because it's clear it shouldn't be done!"
Interestingly, this was the first time he had heard of MedSolutions, but it certainly wouldn't be the last. Within a week or so, Dr. Torelli saw an ad that MedSolutions was seeking a cardiologist to serve as associate medical director. If it had not been for his office administrator showing him the MedSolutions criteria, it would have been unlikely that the ad would have even caught his eye.
Dr. Torelli wasn't thrilled with his current arrangement but was not actually looking at new position at the time. After seeing the ad and thinking about it, he decided to apply for the MedSolutions position and interviewed. He was uncomfortable leaving clinical medicine and did not have high expectations. Five minutes into the interview, he felt completely comfortable. "I met with the other physicians and they were all trying to do the right thing – ensure the patient receives that most appropriate test or procedure". He acknowledged he had expected to hear about a policy to deny a certain percentage of requests, but this was not the case. He was pleased to hear that there were no bonus incentives tied to denials.
It was a frightening prospect to leave clinical practice entirely, but MedSolutions really wanted someone full-time and he told them that he had to think about it. "The next week" Dr. Torelli says "the group decided that it would be in their best interest to part ways with me. I didn't want to say it, but I was ecstatic."
He had found himself looking for a place that was more focused on the human element, and MedSolutions called to him. "All those little events had to occur in a certain order in a short period of time, and it all somehow worked out...all of those events occurring in that order seems unlikely in retrospect," he said.
Dr. Torelli found that he is not uncomfortable saying "No" when a request is inappropriate. He says it's an important part of the eviCore culture to not think in terms of denial and approvals but rather in terms of appropriateness of a request. If a request is appropriate, then you do the test. If on the other hand it's inappropriate, then it shouldn't be done. He is there to listen to and understand the provider's assessment, and to make sure the patient is getting what they need. Not anything less, but not anything more, either. It is his goal to continue to engage and establish relationships with providers to make the healthcare system work better, and to improve patients' experience on their journey to good health.