Prior authorization: Let the consensus begin … today!

Recently, a group of industry associations issued a Consensus Statement on Improving the Prior Authorization Process across the healthcare ecosystem. It was great to see such wide-ranging collaboration of both payer and provider organizations support an action-oriented statement for the ultimate benefit of all involved, especially patients and members.

It’s a very good start and surprisingly forward-looking. However, after studying the carefully crafted language, I say, why look forward? Let’s get going today!

About the Consensus Statement

An alphabet soup of provider-centered organizations supported the statement, including the American Medical Association (AMA), the American Hospital Association (AHA), American Pharmacists Association (APhA), and the Medical Group Management Association (MGMA). On the payer front, America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association (BCBSA) both supported the statement.

In a nutshell, the statement focuses on improving the prior authorization (PA) process from end to end for the benefit of all stakeholders. The group aims to reduce and tighten the scope and breadth of PA while improving communication and continuity of care for patients. All of these are admirable and worthwhile goals.

However, one of the goals in the statement that caught my attention focuses on “transparency and communication.” It looked at actions we can take to make the process better.

It states, “Effective, two-way communication channels between health plans, health care providers, and patients are necessary to ensure timely resolution of prior authorization requests to minimize care delays and clearly articulate prior authorization requirements, criteria, rationale, and program changes.”

This part of the statement on transparency and communication is what I believe we can get started on today.

What does it mean for prior authorization today?

I was struck by the orientation of the statement on inter-organizational collaboration. I have been studying the problem of collaboration for PA and other healthcare processes for almost five years. In that time, I have learned that collaboration is an incredible challenge across the healthcare ecosystem for PA and other processes.

The challenges include competing incentives; heterogeneous (and non-interoperable) systems; multiple, overlapping standards and communication protocols; and, finally, standards that require complex and expensive system changes that hinder adoption.

In fact, I think the biggest challenge to “transparency and communication” is simply the lack of data about adoption costs and benefits. This makes it very difficult to build and deliver effective return on investment models for business executives who decide on investments. We all acknowledge the problem, but we must equally acknowledge that we have done a less than complete job providing quantitative data.

How to act on the Consensus Statement – today

I hope the authors of the Consensus Statement read this post. I have some great news for them. A simple, cost-effective solution is available for prior authorization today. It’s called OnBase Mackinac – a secure, two-way workflow bridge between healthcare organizations. The solution securely exchanges information electronically, guarantees delivery, and facilitates collaboration.

The result?

More accurate, consistent, and faster processes; greater transparency; less risk; and lower costs. We know this because we worked with 2,000+ healthcare payers, providers, Medicare MACs, Durable Medical Equipment suppliers, Home Health Facilities, Skilled Nursing Facilities, and Long Term Care Facilities to improve their inter-organizational workflows, transparency, and communication. Throughout those five years, we made sure OnBase Mackinac supports claims attachments, appeals, prior authorizations, HEDIS, risk adjustments, and a number of other workflows.

To the AMA, AHA, APhA, MGMA, AHIP, and BCBSA I say this: OnBase Mackinac can help you quickly, simply, and cost-effectively begin to address the PA problem you discussed in your Consensus Statement. And it can help you today. I believe you have done great work to build consensus among a diverse array of organizations.

Now is the time to turn those bold words into action.

If you are at HIMSS 2018, please come check out Mackinac in booth 5743. I hope you find that it can deliver on the aspirations you have so eloquently laid out in your Consensus Statement. I look forward to speaking with you.

* This post was originally published on LinkedIn.

Mike Hurley

Mike Hurley

Mike Hurley is the industry manager for Health Insurance at Hyland, helping health insurance organizations transform business processes that drive value for members, providers and employees. Mike works with current and prospective customers to use our award-winning product, OnBase, to drive business transformation. He is also responsible for our high-value, high-impact health insurance solutions, the like Mobile Medicare Enrollment Solution for OnBase. Prior to joining Hyland, he was the founder and president of Swim Lane Software, LLC. Hurley founded Swim Lane in 2007 to create a solution that leveraged Software as a Service (SaaS) technology to automate the processing and adjudication of Medicare Claims through unique use Business Process Management (BPM) and Business Rules Management Systems (BRMS) technologies. Preceding Swim Lane, he founded Green Square in 1997 as a national consulting practice that connected technology with business strategy. As a boutique services firm, Green Square was aimed at driving stakeholder value at over 25 BlueCross BlueShield plans in the U.S. Prior to Green Square, Hurley founded Avalon Technologies, Inc., an award-winning systems integrator focused on Enterprise Content Management (ECM), workflow and Optical Character Recognition (OCR) technologies.

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