Getting to “Yes” faster with prior authorization

How EviCore by Evernorth is reducing providers’ administrative burden

EviCore by Evernorth® is working on parallel tracks to continuously 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, simplify, and speed up prior authorization (PA). We’re also right-sizing the services that require PA and decreasing 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.

Leading on innovation to automate, simplify, and speed up UM processes

We are the PA market leader in automating artificial intelligence (AI) and establishing electronic PA connections. EviCore intelliPath solutions, used by over 180 provider organizations nationally, help streamline PA reviews and get providers to “yes” faster.

This technology has three components:

• EviCore intelliPath AI accelerates real-time decisions, approving roughly half of our authorizations within seconds through advanced predictive AI algorithms. This frees providers from the time-consuming burden of filling out medical necessity surveys, dramatically reduces turnaround times and allows us to focus on complex UM review cases. The 2.5 million EviCore intelliPath AI approvals in Q1 2024 reduced provider case-submission time by 20%.
• EviCore intelliPath Connected leverages bidirectional electronic medical record (EMR) connectivity to automate member eligibility verification, case creation, PA request submission and status updates. Used in conjunction with EviCore intelliPath AI, this creates a touchless experience for providers, allowing them to stay in their EMR workflow: Real-time PA approvals are recorded in seconds after providers order or schedule procedures. The 300,000 EviCore intelliPath Connected authorizations created within the EMR in Q1 2024 reduced provider case-submission time by 90%. Evicore intelliPath Connected is a growing capability that has doubled the number of provider connections every year since its inception in 2019.
• Evicore intelliPath Clinicals automates the collection and submission of relevant clinical documentation when clinical review is required. It uses the Fast Healthcare Interoperability Resources (FHIR) application programming interface (API) standard as well as our own evidence-based guidelines to eliminate providers’ need to attach documentation to a case. The system’s near real-time attachment speed and high-quality document creation decreases overall decision-turnaround time by up to 50%.

Connecting these three components creates an end-to-end touchless EviCore intelliPath workflow, thereby reducing providers’ PA interactions.

As an important note, 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.

Beyond EviCore intelliPath, we are collaborating with CodeX, which is working to accelerate adoption of the Health Level Seven (HL7) 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 PA 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 PA 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 reevaluated our UM solutions and will phase out PA for some services in our radiology, cardiovascular and sleep solutions by a targeted date of January 1, 2025. This effort is intended to give back valuable time to providers and enable us to focus on the aspects of our programs that are most impactful for patients.

This change will also improve the patient experience. Without the need for PA, 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 identified for the program are as follows:

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

In addition, within our medical oncology solution, we’ve launched a program to increase turnaround times and reduce follow-up requests. For some simpler clinical scenarios, this process requires less information to confirm approval 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 PA in favor of a modified retrospective case review process focused on clinical quality.

Exploring the future of UM

As a result of these efforts, our UM solutions are faster and easier to use than ever before. PA is being deployed in the areas where it can provide the most benefit for patients. Providers’ administrative burden is being 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.