Getting to “Yes” faster with medical necessity reviews

How to reduce providers’ administrative burden

When people are sick or need care, they expect their providers to make the right decisions on their behalf – no exceptions. However, providers face many challenges, including the rapid pace of medical innovation and expanding administrative duties. As a result, two-thirds of providers report feeling overwhelmed by the amount of information required to care for their patients.¹ And, as they see more patients than ever, providers and their staff spend 12 hours completing medical reviews each week.²  

The need for supportive clinical partnership and streamlined processes to get patients the right care quicker has never been more critical. That’s why there is continuous work being done to improve the utilization management (UM) solutions we offer today and transform the solutions we’ll offer tomorrow. 

Reducing the administrative burden for providers is a major focus of our efforts. We’re doing that by using innovation to automate approvals, and streamline medical necessity review processes. We’re also right-sizing the services that require medical necessity review and focusing the information needed for those requests where possible. Our goal is a system that works better for providers, delivers the best possible care for patients, and helps payers continue to serve their members efficiently and effectively. 

Using automation and connectivity to simplify and speed up UM processes

EviCore is the market leader in bringing together automation and connectivity to improve providers’ medical review experience. We leverage technology to minimize the need for human input and maximize the ability of systems to exchange information.  

EviCore intelliPath® is our electronic medical necessity review solution used by provider organizations nationally to help streamline reviews and get providers to “yes” faster. It has the ability to create an end-to-end touchless workflow for these requests. It also accelerates real-time approval decisions using advanced predictive AI algorithms, approving roughly half of authorizations within seconds. As an important point of emphasis, we only use AI to facilitate faster approval of cases and improve workflow efficiency. For any other decision, there’s a highly skilled human being involved.

EviCore intelliPath® also frees providers from the time-consuming burden of filling out medical necessity review clinical surveys. It automates member eligibility verification, case creation, medical necessity review request submission and status updates using bidirectional electronic medical record (EMR) connectivity.

To eliminate providers’ need to attach documentation to a case, EviCore intelliPath® uses the Fast Healthcare Interoperability Resources (FHIR) application programming interface (API) standard, as well as our own evidence-based guidelines to automatically retrieve and attach medical record data. EviCore intelliPath’s® near real-time attachment speed and high-quality document creation decreases overall decision-turnaround time by up to 50%. Using the FHIR standard not only puts us on a path to better EMR connectivity in the future, but it also helps ensure we’re on track to comply with the Centers for Medicare & Medicaid Services (CMS) Advancing Interoperability and Improving Prior Authorization Processes final rule.

To complement the EviCore intelliPath® work, we are collaborating with CodeX, which is working to accelerate adoption of the FHIR standard to help drive better communication across the health care ecosystem. Through our participation in CodeX’s oncology-focused pilot program, we’re working to improve the exchange of medical necessity review information between payer and provider systems via EMR. 

Launching initiatives to reduce provider administrative burden

While we’ve made significant strides in streamlining our processes, EviCore is also working to right-size the number of services requiring medical necessity review and lessen the information needed for those requests when possible. This approach enables us to reduce the administrative burden for providers while continuing to ensure better outcomes for patients and deliver value for our clients.  

For example, we phased out medical necessity review requests for some services in our radiology, cardiovascular and sleep solutions to give back valuable time to providers and let us focus on the aspects of our programs that most impact patients.

This change will also improve the patient experience. Without the need for medical review, some patients may be able to take advantage of same-day services, when available, which is more convenient and saves them from a second appointment.

Specific services that have been phased out include:  

• Radiology: some nuclear medicine studies (e.g., bone density scans) and ultrasounds  
• Cardiovascular: echocardiography  
• Sleep: home sleep apnea testing  

In addition, within our medical oncology solution, we’ve launched a program to improve turnaround times and reduce follow-up requests. For some simpler clinical scenarios, this process requires less information to confirm medical necessity while still adhering to evidence-based medicine.

We have also developed a radiation oncology “episode of care” model, in which providers agree to a fixed reimbursement per episode of radiation therapy. In exchange, they get guaranteed reimbursements and the removal of medical review in favor of a modified retrospective case review process focused on clinical quality.

Exploring the future of utilization management

As a result of these efforts, EviCore’s utilization management solutions are faster and easier to use than ever before. Medical necessity review is deployed in the areas where it can provide the most benefit for patients. Providers’ administrative burden is meaningfully reduced, and we’re looking for even more ways to reduce it further.

The UM of the future will shift from a model that enforces clinically appropriate care to one that enables providers to deliver it through a partnership framework. This will require leveraging tools holistically and centering them on the patient’s individual care. 

Want to learn more? Read our white paper about the rapidly evolving UM landscape.