To help improve clinical and financial outcomes, payers and providers must work together to collaboratively leverage cloud-based solutions.
Key takeaways:
- The current prior authorization (PA) process is known for being labor intensive, time consuming, and costly for payers and providers.
- The Centers for Medicare & Medicaid Services (CMS) recently issued proposed rules that were created to streamline the PA process across all payers.
- Payers can utilize PINC AI™ Stanson to meet CMS regulatory requirements. The PINC AI™ Stanson PA solutions use machine learning (ML), and clinician codified and validated PA policies to automate the manual process, which can reduce the wait time from days to less than a minute.
PA is one area in health care where payers, providers, and patients all agree could use some improvement. PA is a utilization management (UM) strategy that payers use to help ensure patients can access the most cost-effective treatment available for their clinical needs. Providers must submit specific paperwork to payers to obtain approval of a health care service or medication before the care is administered.
The PA process sounds great on paper, but it can pose an administrative burden to both payers and providers. It’s also known as being one of the most taxing pain points in payer-provider collaboration. In its current form, PA is a time-consuming, manual process that may cause care delays that could put patients at risk. As the health care sector continues to evolve toward value-based care, PA modernization is a way for payers and providers to help cut costs and deliver more value to patients.
New CMS rules could expedite the PA process
With this in mind, CMS proposed new rules for health care payers that aim to streamline the PA process. The proposal includes requirements for certain payers to:
- Move to electronic PA (ePA) by 2026.
- Provide specific reasons when denying PA requests.
- Publicly report certain PA metrics such as the percentage of PAs that were approved and denied, the percentage of PA requests approved after appeal and the average time for a PA determination.
- Reduce the amount of time they have to consider PA requests and notify beneficiaries. Standard PA notification periods will be shortened from 14 to seven calendar days for Medicare Advantage and Medicaid managed care plans.
PINC AI™ Stanson can help reduce the burden of PA
There has never been a better time to stay ahead of regulations and advance patient care. While these changes won’t happen immediately, in the meantime, payers and providers can utilize PINC AI™ Stanson to implement many of the rules proposed by CMS. In order to help improve clinical and financial outcomes, payers and providers must work together to collaboratively leverage cloud-based solutions. PINC AI™ Stanson developed four tools that offer an appealing alternative to streamline the burdensome PA process:
- ImagingGuide offers targeted point-of-care imaging clinical decision support (CDS) to give clinicians the tools to aid in the decision-making process, helping the provider reduce clinically inappropriate and potentially harmful orders.
- AuthAssist integrates into the electronic health record (EHR) workflow to provide point-of-order ePA with near instant approval resulting in reduced time delay for both patients and providers.
- ReviewAssist offers real-time approval validating a patient’s eligibility and clinical necessity with artificial intelligence (AI) assisted review that can help reduce annual spend on PA.
- ImagingAssure provides full-service radiology benefits management (RBM) services certified by URAC and includes PINC AI™ Stanson radiologists on staff to guide ordering physicians for the best possible patient outcome.
These solutions help give payers and providers the ability to jumpstart the PA process in a way that benefits all parties and ultimately improves care. Since PA decisions are delivered quickly and efficiently, clinical reviewers can devote more time to the most complicated cases. The provider and patient can get peace of mind and can move forward with treatment plans right away. Plus, PINC AI™ Stanson's PA solutions benefits payers since the technology improves care outcomes, which can ultimately lower reimbursement rates and cut per member per month (PMPM) spending in high-cost patient groups. Furthermore, PINC AI™ Stanson’s PA solutions can help eliminate communication barriers between payers and providers, which can be costly for both sides.
Final thoughts
The love-hate relationship with PA doesn’t have to be the norm. ePA shows promise to balance the need for affordability and access to high-quality care. PINC AI™ Stanson’s PA solutions yield valuable insights, which can help advance CMS’s ePA implementation forward.
Start conversations now about the potential impact the CMS PA proposed rules could have on your health care organization. Learn more about how PINC AI™ Stanson can help you streamline the PA process.
About the author
Ryan M. Nellis, vice president & general manager, Stanson Health, a Premier (PINC) company, leads a team of clinicians, engineers, and data science experts who work together to deliver AI-infused solutions to improve patient care and health costs via a growing client network of over 650 hospitals and 400,000 physicians.
Nellis is a growth-oriented leader who delivers business value in investor/venture and PE-backed, high-growth, public and private companies. He has developed and executed strategies in the health analytics and real-time clinical decision support solution markets–from both the provider and payer perspectives.