Sep 12th 2022

Making Prior Authorization Work for All of Us

No matter your role in healthcare, you're likely aware of prior authorization (PA). While some providers and patients find PA time-consuming and frustrating, it remains the best way to help ensure patients receive safe, appropriate and effective care at the lowest overall cost to U.S. healthcare. Recent advances in technology are making PA smarter, more automated and faster than ever before. 

Why is Prior Authorization Necessary?

Medical knowledge is estimated to double every 73 days today compared with every 3.5 years in 2010.1 At that rate, it’s virtually impossible for many doctors and healthcare professionals to keep up with every change to treatment guidelines. For example, about 20% of cancer patients fail to receive treatment plans matching NCCN® guidelines, the recognized industry standard.2 Also, doctors estimate that one-fifth of medical care delivered is unnecessary.3 And experts have calculated that about 250,000 lives are lost each year due to medical error – the third-leading cause of death in the United States. PA addresses all these challenges.

Clinical Benefits

PA protects patients and drives better outcomes by ensuring tests, treatments and procedures are following the latest medical knowledge. Companies like eviCore that manage the PA process on behalf of health plans apply the latest evidence-based medical guidelines to a provider’s request. The guidelines are proven recommendations for how to treat certain conditions developed by physicians with expertise in that clinical area. 

Cost Benefits

Unnecessary tests and treatments result in significant costs for plans and can be expensive for patients, especially in the deductible phase. PA reduces costs for payers and patients without compromising care quality. For example, if there are clinically equivalent treatment options, PA helps ensure the one that’s selected is the most cost-effective treatment for the patient’s condition, based on the individual’s coverage. 

PA in Practice

Here’s another example: A common first test in diagnosing many pediatric conditions is a CT scan. Yet, in specific cases, the PA process advises to skip the CT scan when the patient will need an MRI no matter the results of the CT scan. This saves vital time in diagnosis and treatment for the provider and patient and avoids unnecessary cost for the patient and plan.

Intelligent PA is Here

Over the past several years, eviCore has invested heavily in automating PA to help improve the provider and patient experience. At least 75% of PA requests submitted electronically (ePA) are approved immediately or within an hour and more than 90% are completed within 24 hours. If a doctor’s initial PA request is denied, then it goes through further review, which can include a peer-to-peer consult with a medical director who shares the doctor’s clinical background.

Our intelliPath® artificial intelligence technology replaces clinical surveys to enable a faster, more efficient PA process. It leverages clinical data from more than 125 million cases to train our algorithms, enabling automated case creation and submission; real-time, touchless case approvals; and more convenient provider access to case status. The faster the approval, the sooner patients can get the clinically appropriate, cost-effective care they need.

References:

1 Densen, P. (2011); Challenges and Opportunities Facing Medical Education. Trans Am Clin Climatol Assoc. 122: 48–58. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116346

2 Rausa et al., J Clin Pathways (2020, Jan/Feb); Use of Clinical Decision Support and Peer Review to Increase NCCN Guideline Adherence. 5(1):54-56 doi:10.25270/jcp.2020.2.00111. https://www.hmpgloballearningnetwork.com/site/jcp/article/use-clinical-decision-support-and-peer-review-increase-nccn-guideline-adherence

3 Johns Hopkins Univ. (2017, Sept. 6); Unneeded Medical Care is Common and Driven by Fear of Malpractice, Physician Survey Concludes. [Press release] PLOS ONE. https://www.hopkinsmedicine.org/news/media/releases/unneeded_medical_care_is_common_and_driven_by_fear_of_malpractice_physician_survey_concludes

4 Johns Hopkins Univ. (2016, May 3) Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S. https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us