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.”