Elevance Health is moving toward a simpler and more streamlined clinical review process through its Health OS platform.
Health OS is a secure data platform built by payers to integrate data from key sources such as electronic health records, laboratories, and health information exchanges to support faster clinical decision-making without significant administrative effort from providers.
It also connects with other data systems, such as Epic’s Payer Platform, to match the data you need. Elevance was the first company to rely on Epic’s tools to address concurrent inpatient care reviews, which occur when a patient is admitted for one condition, such as treatment for pneumonia, and then develops a co-occurring issue, such as sepsis.
These types of reviews have traditionally required manual documentation, which can result in delays, incomplete information, or additional administrative effort.
Ashok Chennuru, chief data and digital transformation officer at Elevance Health, told Fierce Healthcare that Epic’s platform helps bring together disparate data sources into a common format, making it easier for teams to use. Epic’s integration with many providers also allows for pre-approvals in a more streamlined manner, he said.
This commitment to simultaneous review fits into Elevance’s broader commitment to payment accuracy and completeness and ensures that claims are paid properly the first time, he said.
Chennuru said refusals are often due to missing or missing information. Addressing this issue is a win-win for everyone involved in the transaction: payers, providers, and patients.
“Most of the providers we have talked to are willing to work with us because they see it as a clear win-win for both of us,” he said.
Through Health OS, the insurer saw a 61% reduction in prior authorization denials and a 60% reduction in cases placed on “pending” due to missing information related to concurrent reviews.
Additionally, Elevance found that follow-up reviews, including peer-to-peer discussions and appeals, decreased by 51% as submitted information became more complete. Additionally, through collaboration with some health system partners, we have been able to save approximately 15 minutes of administrative time per case.
Mr. Chennuru noted that the time savings as a result of the program were significant and positive. The platform also supports increased transparency for providers, the insurer said.
“Now we can get them to focus on the real value,” Chennuru said.
Beyond concurrent reviews, Elevance Health relies on Health OS to enhance its use of electronic prior authorizations. Last year, the company was one of many companies to sign an industry pledge to move to electronic prequalification submissions.
Elevance said in the announcement that it has electronically processed more than 250,000 prior authorizations since April and has 30 health systems actively participating in its digital program.
The insurer said 42% of these decisions were resolved within one minute.
Electronic pre-authorization speeds patient decision-making and further reduces the paperwork required to manage submissions, the company said.
Chennuru said these programs are an important step towards a more technologically enabled future where these administrative processes run much more smoothly for the benefit of all stakeholders.
“We use that information to address gaps in care and other clinical insights and take next-best steps to support healthcare providers, as well as simplify administrative processes,” he said. “That’s really where we see this going.”
