A number of health care providers and technology organizations are backing the Centers for Medicare & Medicaid Services’ push to streamline prior authorizations for the health care industry, a move officials say will smooth out the unevenness of widely disliked payer practices.
As teased in a blog post last week, CMS and its administrator, Mehmet Oz, M.D., announced Wednesday that 29 health care providers have agreed to address workflow, technical, and operational issues that are preventing them from implementing electronic prior authorizations, the digital exchange of claims for coverage rather than by letter, fax, or phone call.
Nine of those organizations are large insurance companies that committed to doing so last year, including UnitedHealthcare, Cigna, and Aetna. The remaining 20 are a mix of health systems, including Cleveland Clinic, Sanford Health, Providence and Ochsner Health. Electronic health record vendors such as Epic, Oracle, and athenahealth. It also includes data networks such as eHealth Exchange and b.well Connected Health.
Oz explained the pledge Wednesday afternoon during a fireside chat at the Axios Future of Health Summit, telling the audience that insurance companies were “playing around” with CMS on the issue, but there was little participation from health care providers.
“Fifty percent of previous certification questions are returned by fax,” he said. “It’s very inefficient, it’s very slow, it’s lost, it’s confusing, it doesn’t correlate properly, it doesn’t interact, it has to scan the fax page. It’s just stupid. Fax should be abolished.”
Specifically, 29 “early adopters” cited by CMS have agreed to work toward integrating electronic prior authorization into their clinical and administrative systems. The agency also said it is working to reduce reliance on manual processes such as faxing, increase visibility into the status of approval queries, and broadly improve the way information is passed on at a technical level.
CMS is also working on rulemaking that would require certain interoperability and pre-approval schedules to be implemented by a January 1, 2027 deadline.
If these various efforts come together, Oz said, by January “there will be some settings where pre-authorization is happening and you don’t even know it’s happening, because the insurance company will query the EMR of the hospital or clinic you’re in and automatically pull the data that justifies that you actually need a biopsy of the mole. The doctor doesn’t take the time, you don’t take the time, the insurance company doesn’t take the time. This is billions of dollars wasted.” Every year. ”
In recent weeks, individual insurance companies and their associations have touted their progress in standardizing electronic pre-approval applications. Major health plans saw an 11% decline in pre-authorizations, or 6.5 million fewer applications, with Medicare Advantage seeing an even bigger reduction of 15%.
Providers on the other side of the process have so far expressed skepticism about the purported reductions. Health system executives and management teams frequently cite increased insurer utilization management activity as a headwind to their performance, and survey data released this week by the American Medical Association found that only 1 in 3 physicians believe that insurers’ promises will result in significant improvements.
“After years of unfulfilled promises, physicians’ confidence in insurers’ voluntary commitments has been severely eroded,” AMA President Dr. Bobby Mukamala said in a statement addressing the findings. “Physicians are particularly frustrated when so-called peer-to-peer reviews are conducted by individuals who do not have the appropriate clinical expertise to evaluate patient care. Only one-third of physicians expect meaningful impact, and few report that health plan reviewers are appropriately qualified, highlighting a credibility gap that cannot be filled with vague or partial measures.”
