The ‘to-and-fro’ data exchange between the three Ps (Providers, Payers, and Patients) increases timelines, adding strain to the healthcare ecosystem and affecting the ultimate goal: timely and relevant care to ensure better patient outcomes.

Providers find the process opaque and unpredictable^[3], making treatment decisions difficult. Keeping track of which services are covered, what coverage has changed, and appealing rejections, etc., takes up a lot of provider time that could otherwise be focused on patient care. Eighty-eight percent of physicians describe the burden associated with prior authorization as high or extremely high, and almost all (94%) of them have reported care delays associated with the process.

Image 2: Challenge with the current Prior Authorization process

Payers, on the other hand, must go through volumes of documentation and the strenuous administrative tasks of deciphering the medical necessity, prior treatment, clinical indications, and total cost of therapy. The information is fragmented and comes from various sources. For instance, 76% of payers report fax machines and provider portals as primary sources of prior authorization requests.^[4] This has brought the whole healthcare ecosystem to a much-needed paradigm shift in the form of Electronic Prior Authorization.

Creating new efficiencies with Electronic Prior Authorization

Electronic prior authorization integrates current workflows by electronically transmitting patient information between providers and payers, improving the drug prior authorization process. Though ePA has been around for a decade, its adoption hasn’t been as agile. According to the Council for Affordable Quality Healthcare’s 2023 CAQH Index, only 31% of prior authorizations are fully electronic.^[5]

That is changing now as business realities and regulatory push have created an urgency to embrace ePA. The CMS's final rule^[6] on ePA offers Payers a chance to gain a competitive edge in the market. Payers can set a precedent by adopting a much-needed member-centric initiative. The new CMS Rules have the potential to expedite and streamline the process, building member trust and adding business value. In addition to being compliant, ePA offers several strategic advantages to payers:

These use cases represent the potential of democratised cognition to solve many existing healthcare challenges. That said, Generative AI also presents its own share of ethical and technological concerns, such as systemic biases, privacy and confidentiality, the impact of hallucinations, and so on. Here are a few considerations for healthcare organisations to keep in mind as they embark on their Generative AI journey:

Shifting to an efficiency-driven authorization process

Electronic Prior Authorization is the way forward for Payers who want to remain current, improve information exchange timelines, and provide superior member experiences. However, the transition to new processes after investing heavily in the existing systems can be daunting, and the idea of change can seem unsettling. However, a frictionless transition to ePA is a possible reality that can be manifested through existing platforms and investments, causing minimal disruptions in the existing architecture. Payers can change the trajectory of how they gain value from their business with an intelligent mix of new tools and solutions seamlessly integrated with existing technologies. In the next article, we will explore the precise roadmap that Payers can follow in adopting ePA for a smoother transition. 

References

1. 1. AMA prior authorization (PA) physician survey (ama-assn.org)
2. 2. AI ushers in next-gen prior authorization in healthcare (mckinsey.com)
3. 3. What doctors wish patients knew about prior authorization (ama-assn.org)
4. 4. Prior authorization practice resources (ama-assn.org)
5. 5. 2023 CAQH Index Report | A New Normal: How Trends From the Pandemic are Impacting the Future of Healthcare Administration (caqh.org)
6. 6. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F (cms.gov)
7. 7. 3Q23 Prior Authorization: U.S. Healthcare Payer Perspectives (gartner.com)
8. 8. Tackling healthcare’s biggest burdens with generative AI (mckinsey.com)