By Hans Buitendijk, chair, EHR Association.
Having identified the existing prior authorization process as a burden with wide-ranging impacts across multiple healthcare domains – contributing to provider burnout and care delays that put patients at risk – the Office of the National Coordinator for Health IT (ONC) is seeking solutions that leverage its Health IT Certification Program to advance electronic prior authorization (ePA).
An analysis by RTI International on behalf of America’s Health Insurance Plans (AHIP) agrees that the ONC’s objective is worthwhile. Published in Evaluation of the Fast Prior Authorization Technology Highway Demonstration, the analysis examined prior authorization transactions before and after implementation of ePA and found the time between request and decision was 69% faster with ePA. Time spent on phone calls and faxes also decreased significantly, and transparency of prior authorization requirements was improved.
To help identify the best approach to leveraging its certification program to advance ePA, ONC in January 2022 solicited stakeholder input on incorporating standards, implementing specifications, and establishing certification criteria for HIT supporting providers and payers likely involved in ePA. The EHR Association responded by recommending a staged approach to establish a glidepath that enables needed flexibility and ensures availability of relevant software support.
ONC’s Reduction Strategy
Prior authorization is a complex process requiring collaboration across multiple domains within an individual healthcare organization and across potentially dozens of health plans covering its patient population. This, according to ONC, results in a process in which “diverse payer policies, provider workflow challenges, and technical barriers create an environment in which the prior authorization process is a source of burden for patients, providers, and payers; a cause of burnout for providers; and a health risk for patients when it delays their care.”
The specific challenges identified by ONC in its Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs include:
- Difficulty in determining whether an item or service requires prior authorization
- Difficulty in determining payer-specific prior authorization requirements for those items and services
- Inefficient use of provider and staff time to navigate communications channels such as fax, telephone, and various web portals
- Unpredictable and lengthy amounts of time to receive payer decisions.
ONC also noted that payers and health IT developers “have addressed prior authorization in an ad hoc manner with interfaces that reflect individual payer technology considerations, payer lines of business, and customer-specific constraints.”
The Current Landscape
While efforts to streamline prior authorization processes will require a significant amount of coordination and standardization, the industry isn’t starting from scratch. HL7’s Da Vinci Project has already developed three Implementation Guides that provide a starting point for outlining the general flow and interactions across the modules and systems that will be needed for a full end-to-end prior authorization workflow.
While these Guides – Coverage Requirements Determination (CRD), Documentation Templates and Rules (DTR), and the Prior Authorization Support (PAS) – show promise, they are not yet sufficiently mature to enable adoption in certification. Further, adopting criteria to require the support of all three guides could be challenging because of the unique health IT needs and configurations at individual provider organizations, differences in how products are developed, supported, and marketed, and the current structure of ONC’s certification program.
Provider organizations have widely varying approaches to the adoption and deployment of health IT systems. Some use a single, integrated solution encompassing all the functionality required to enable prior authorization. Others may have capabilities for prior authorization and financial management distributed across multiple solutions from different vendors.
Further, the prior authorization process can be triggered at multiple points, such as a clinician entering an order into an EHR or office staff at the time an appointment is scheduled, possibly using different HIT. Collection of data to support a request may involve accessing the necessary supporting information directly from an EHR, or gathering documentation from multiple systems, or still manually.
Another layer of complexity is added when a plan’s prior authorization requirements necessitate follow-up for the submission of additional data. Lastly, once submitted, responses from the payer are of interest to not only the requesting provider but also back-office revenue cycle staff and patients.
Because of these complexities, boundaries delineating which health IT would support specific interactions and thus what health IT should or need not be certified to which interactions are not yet fully understood within the respective Implementation Guides. Therefore, it is premature to require certification of a full prior authorization workflow for provider-focused health IT, particularly singular health IT such as an EHR, considering both the variety of practical, valid configurations of health IT, and the absence of clearly defined, more granular interaction sets within the respective Guides that certification criteria can reference.
A Staged Approach
Based on these considerations, EHRA recommends taking a phased and focused approach to advancing ePA capabilities across the relevant health IT landscape. Doing so would ensure an important level of flexibility while the guidance is maturing and optimum configurations are established without creating undue certification and provider adoption burdens.
As such, we recommend ONC take the following staged approach:
Stage 1: Work with the Centers for Medicare and Medicaid Services (CMS) to focus adoption and certification of the CRD, DTR, and PAS Implementation Guides on the payer side and establish a clear implementation standard for any interactions with payers supporting prior authorization. Certification criteria for provider-focused health IT should not be set until there is clarity on how specific functional needs supported by the Guides map to the various systems in use at healthcare organizations to support prior authorization, including certified EHRs, non-certified health IT, and SMART on FHIR apps.
The presence of standardized payer APIs for prior authorizations will encourage developers to determine how to best adopt the same standards as payers, specifically for those interactions performed by the health IT. Further, ONC should make test harnesses available for the respective interactions that can be exercised individually.
In terms of implementation, the initial focus of Stage 1 should ideally be on CRD and PAS interactions due to the substantial complexity of managing the DTR capabilities on the provider side. For example, full transparency of data requirements is needed for each service, item and/or procedure requiring authorization to enable providers to effectively grant automated access to and gathering of the necessary data in their health IT.
Stage 2: Establish certification criteria based on the matured and evolved interaction distributions across health IT, with the typical interaction sets documented clearly within each Implementation G Further, extend the provider functional requirement for prior authorization engagement with the use of certified health IT to support the prior authorization workflow.
While there will be a progression and expansion of the basis on which health IT is certified, we strongly recommend that providers be fully supported over time by a suite of certified health IT for the full prior authorization workflow.
Adoption of ePA promises to reduce the administrative steps necessary to obtain authorization while enhancing the transparency of requirements dictating when authorization is needed and what documentation is needed for substantiation. It should also improve payer responsiveness along with the usefulness and clarity of responses, thus providing for better integration with provider workflow.
Ultimately, by adopting a focused, phased approach to advancing ePA capabilities that takes into consideration the impacts on providers, payers, health IT developers, and patients, ONC can successfully streamline the prior authorization process. In doing so, provider burdens will be eased, the process accelerated, and transparency achieved to the benefit of all.
The full EHRA response to ONC’s Request for Information can be found here.
Hans Buitendijk, MSc, is hcair of the EHR Association, director of interoperability strategy at Cerner Corporation, and a member of the Health Information Technology Advisory Committee (HITAC).