Prior Authorization’s Next Stage: Reducing the Administrative Burden

Medical knowledge is growing at an unprecedented rate, which is accelerating every year. This information explosion has created a challenging environment for providers. A recent survey found that 95% of physicians want to learn more about new treatments, procedures, and trials that could help improve outcomes for their patients, but more than two-thirds feel overwhelmed by the amount of information they have to keep up with. As a result, there can be significant knowledge gaps when it comes to caring for patients in ways that align with the latest medical evidence.

That’s why prior authorization is so important. It keeps providers up to date on critical nuances in treatment, procedures, and clinical guidelines. Which helps them ensure that their patients receive the most optimal treatment based on their precise diagnosis, prognosis, and latest clinical evidence. Prior auth expedites connecting patients with the right treatment. Achieving a better health outcome sooner; whether that’s a full recovery or optimal management of chronic conditions.

Helping Patients Get Evidence-Based Care

Here are a couple of real-world examples of how prior authorization supports providers. They work to help patients get the evidence-based care they need.

• Molecular profiling is a form of genomic testing. It can confirm the presence of specific cancer tumor gene mutations that are best treated with more targeted therapies. But, up to 30% of patients with advanced non-small cell lung cancer (NSCLC) don’t get the most effective treatment. All because they didn’t get molecular profiling. By getting this testing, patients have better outcomes: longer survival and less toxic treatment. We found that 40% of doctors skipped this testing without prior authorization. Once prior auth introduced the requirement for testing, around 25% of patients switched to the more effective treatment based on the results. The adherence to testing was nearly 100%.
• For young children with headaches, many providers start with a CT scan, which is a less expensive test than an MRI. But, the evidence-based guidelines indicate that an MRI is the better option because of the quality of the image produced. The prior authorization process directs the provider to skip the CT and do the MRI. This helps the patient avoid potentially harmful delays in diagnosis and the co-pay associated with the extra test. It also helps the patient avoid the radiation associated with a CT scan. This is particularly important for children who are both more sensitive to radiation and have a longer lifespan for any radiation-related issues to manifest.

Three Steps to Improve Prior Authorization

Right now, prior authorization, while helping fill critical knowledge gaps and improving outcomes for patients, can increase provider administrative burden. However, there are ways to make it more efficient and collaborative.

1. Engage with providers earlier to help with clinical decision-making. Typically, prior authorization takes place after a clinician decides on the recommended tests and/or course of treatment. By incorporating the process earlier in the work stream, providers get access to the most up-to-date clinical evidence from the start. Giving them a powerful resource to help identify the most clinically appropriate treatment. This approach also provides more opportunities for partnership with the provider on the front end to ensure the best possible plan for the patient going forward.

2. Increase automation. Some current approaches to prior authorization can involve cumbersome administrative processes. Electronic prior authorization is a solution to this challenge that saves time for providers. For example, EviCore’s intelliPath® solution drives quick approvals for certain types of medical services. We’ve processed more than 20 million cases through our artificial intelligence technology, intelliPath AI, and we’re saving about 2 minutes per case. Through intelliPath Connected, providers can connect their electronic medical records to our portal so that all the information needed for a prior authorization request is automatically connected. intelliPath Connected reduces the case-creation and submission time by an additional 8 minutes per request, so the time savings add up fast!

3. Empower patients in the process. Right now, patients aren’t that involved in—or even aware of—the prior authorization process. However, it’s important to help demystify prior authorization for them, and there’s a role to play for both providers and companies like EviCore. Not only would added transparency help patients stay informed of authorization decisions, but it would also allow for educational opportunities about their condition and appropriate treatment options. Additionally, bringing patients into the prior authorization process can help close information gaps, as patients would have an opportunity to provide any missing information from the provider’s request that would otherwise delay authorization approvals.

These new approaches enable a more efficient exchange of information and more opportunities for collaboration. As a result, gaps in medical knowledge are filled, the administrative burden is reduced, and it becomes even easier for patients to get the care they need.